Examining the characteristics of adolescents recruited to a novel digital treatment for eating disorders. Baseline findings from an open feasibility trial

Examining the characteristics of adolescents recruited to a novel digital treatment for eating disorders. 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Baseline findings from an open feasibility trial Guri Holgersen, Emilie S. Nordby, Irene Bircow Elgen, Ester Marie S. Espeset, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7556084/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Digital interventions for eating disorders have the potential to increase access to care and broaden the range of treatment options for adolescents. However, little is known about the characteristics of those who seek these interventions. Identifying such characteristics will help to ensure that these interventions meet the needs in the target population, highlight potential unrepresented groups, and support clinicians in assessing clinical suitability for individual patients. This study aimed to i) examine the characteristics of adolescents seeking digital treatment for eating disorders within routine clinical care and ii) explore whether the key components of the novel digital treatment align with the characteristics of the adolescents it is designed to support. Methods This study utilised baseline data from an open feasibility trial of a novel digital treatment for eating disorders within routine clinical care. Participants were adolescents aged 15–18 years, with a diagnosis of atypical anorexia nervosa, atypical bulimia nervosa, binge eating disorder, or eating disorder, unspecified. Baseline assessment included: Demographic characteristics, eating disorders symptomatology, psychosocial impairment, emotional dysregulation, anxiety, depression, negative self-evaluation, and motivational factors. Results A total of 25 adolescent participated in the study, only female. Mean age was 16 years. Half of the adolescents had previously received face-to-face treatment for an eating disorder. The sample was transdiagnostic with some variation in distribution. The adolescents reported severe eating disorder symptoms, marked psychosocial impairment, emotional difficulties, elevated negative self-evaluation and high levels of internal pre-treatment motivation. Conclusion The findings from this study underscore the relevance of digital interventions to complement or extend traditional eating disorder care for adolescents. This study emphasises the importance of designing digital treatments that are sensitive to normative biases, address the multifaceted nature of eating disorders and are tailored to the needs and preferences of a transdiagnostic population. Present findings are important insofar as they may inform that the key treatment components align with the characteristics of adolescents seeking digital treatment for eating disorders within routine clinical care. Trial registration ClinicalTrials.gov NCT06306586. Approved 05.03.2024. Available online 12.03.2024. eating disorders adolescents transdiagnostic digital treatment routine clinical care developing novel intervention characteristics of help-seeking Figures Figure 1 Figure 2 Figure 3 Plain English summary This study looked at adolescents aged 15 to 18 who were starting a new digital treatment for eating disorders as part of regular healthcare. The goal was to better understand who chooses this kind of help and whether the treatment fits their needs. All 25 participants were girls, and half had already received face-to-face treatment before. They had different types of eating disorders and reported serious symptoms, emotional struggles, and low self-esteem. Many were highly motivated to get better. The findings show that digital treatments can be a useful addition to traditional care for adolescents with eating disorders. However, the study also points out that more should be done to include a wider range of young people in these treatments. This will help make sure that digital options are fair and suitable for everyone who needs them. Background Eating disorders are a group of complex clinical conditions characterised by pathological concerns about shape and weight and disturbed eating and weight-control behaviours ( 1 ). Impaired physical health, disrupted psychosocial functioning, and reduced life expectancy are some of the severe consequences of eating disorders ( 2 , 3 ). The disorders are highly prevalent worldwide, especially in adolescents ( 4 , 5 ). Several evidence-based treatments are available ( 6 ) with Family-based treatment (FBT) and Enhanced Cognitive Behaviour Therapy (CBT-E) having the strongest evidence-base ( 7 ). Despite the disorders severity and the availability of evidence-based treatments, most individuals who meet the criteria for a clinical eating disorder do not seek help ( 8 , 9 ). Consequently, eating disorders remain highly undetected and subsequently untreated ( 3 , 10 ) with help-seeking behaviours rates particularly low among adolescents (10%-20%) ( 11 – 13 ). Individual barriers to help-seeking behaviour include poor mental health literacy, stigma surrounding eating disorders, denial of the disorder’s severity, as well as distorted body ideals enforced by social media ( 8 , 14 ). Systemic factors contributing to the existing treatment gap are limited therapist availability, the cost of treatment, geographic isolation from available services, long waitlists, and poor eating disorder literacy among primary care providers ( 8 , 15 ). Moreover, of those who seek help, a sustainable number do not respond to the treatments currently available ( 16 , 17 ). High drop-out rates (29–73%) ( 18 , 19 ) and low remission rates (40–50%) indicate that a substantial proportion continue to exhibit high levels of eating pathology at the end of treatment ( 16 , 20 ). Other factors have also been reported to contribute to make eating disorders particularly challenging to treat. The disorders complex interplay of psychological, biological, and social factors ( 14 , 21 ), the underlying mechanisms being unknown ( 22 ) and the high psychiatric comorbidity (> 70%) ( 23 ) could be some of the reasons. Furthermore, eating disorder treatments often have a categorical approach, despite diagnostic migration is common and diagnoses vary across individuals ( 24 ). In addition, treatments often follow standardised protocols and manuals which do not account for unique individual factors influencing an eating disorder ( 25 ). As a result, individuals with eating disorders can feel alienated from treatment ( 26 , 27 ). Given the abovementioned challenges with treatment for eating disorders, there is a pressing need to both improve access to existing evidence-based treatments and develop novel interventions that address the multifaceted nature of these conditions ( 16 , 22 , 25 , 28 ). A promising approach is treatments delivered via computers or smartphones, often referred to as digital interventions or digital treatments ( 29 , 30 ). The accessibility of these treatments positions them as a valuable component within the spectrum of services for eating disorders, particularly considering the numerous of barriers associated with traditional treatments ( 31 ). Digital interventions can increase access to care and have demonstrated effectiveness for improving symptoms of eating disorders while also being cost-effective ( 6 , 32 ). Although endorsing many of these advantages, most individuals with eating disorders still prefer face-to-face treatment ( 33 ). Moreover, despite a growing evidence base, only a small proportion of existing digital interventions have been developed specifically for adolescents with eating disorders ( 30 ). In addition, digital intervention also faces challenges related to uptake and engagement ( 29 , 34 ) where one contributing factor may be the expert-driven development processes that do not sufficiently reflect the preferences and goals of the intended users ( 35 , 36 ). To address these challenges, there is a need to develop novel digital interventions for adolescents with eating disorders ( 16 , 30 ) based on the perspectives of those who will use them ( 34 , 37 ). Tailoring interventions to adolescents' needs is particularly important, as excluding their voices may undermine the real-world relevance ( 38 ). Simply adapting adult interventions is not sufficient, as adolescents require developmentally and age-appropriate considerations ( 39 , 40 ). Moreover, since these interventions are not suitable or preferred by everyone ( 33 , 34 ) understanding the characteristics of those who engage with digital interventions can help clinicians determine who may benefit from these interventions ( 33 ) and reveal whether certain groups are underrepresented which in turn could indicate a need to adapt the intervention to better fit into the daily lives of the people who will use them ( 34 , 41 ). Despite this there is a significant lack in the involvement of children and adolescents when developing digital treatments and little is known whether the interventions that are designed aligns with their needs ( 42 , 43 ). The current study aimed to i) examine the characteristics of adolescents seeking digital treatment for eating disorders within routine clinical care and ii) explore whether the key components of the novel digital treatment align with the characteristics of the adolescents it is designed to support. Method Study setting and design An open feasibility trial of a digital treatment for adolescents with eating disorders was conducted at the Haukeland University Hospital in Bergen, Norway (ClinicalTrials.gov: NCT06306586). Adolescents receiving the digital treatment were patients at child and adolescent psychiatric outpatient clinics serving both urban and rural areas within the catchment area of the Western Norway Regional Health Authority. These clinics serve a population of approximate 122 000 youth below 18 years ( 44 ). The feasibility trail was aiming to assess feasibility aspects regarding the sample’s representativeness, adherence, acceptability, and preliminary efficacy. In accordance with feasibility trail design, no formal sample size calculation was conducted. To examine the characteristics of the adolescents and explore whether the novel intervention aligns with the population it is designed to support, this study utilised baseline data from participants included in the feasibility trail between March 2024 and May 2025. Results are reported in accordance with the Consolidated Standards of Reporting Trials (CONOSORT) guidelines for feasibility trials [see Additional file 1 for CONSORT checklist] ( 45 ) Study population Inclusion criteria The following inclusion criteria were applied for the feasibility trail: (a) Diagnosed with atypical anorexia nervosa, atypical bulimia nervosa, binge eating disorder, or eating disorder, unspecified ( 46 , 47 ), (b) Age between 15 and 18 years, (c) Stable dose of medication for a co-morbid psychiatric disorder for six weeks, (d) Having a mobile phone with internet access, (e) Speaks and writes Norwegian. Exclusion criteria To ensure the safety of participants during the feasibility testing of a novel digital treatment, individuals with anorexia nervosa and bulimia nervosa were excluded due to somatic complications commonly associated with these diagnose ( 48 , 49 ). Patients with avoidant restrictive food intake disorders (AFRID) were also excluded since the clinical picture is different from the other eating disorders ( 46 ). Further, having a co-morbid medical condition or disorder known to influence eating or weight (i.e., pregnancy, cancer), psychotic disorders, acute suicidality, substance abuse, substance dependence or severe depressive episode were exclusion criteria. Receiving inpatient treatment for a psychiatric disorder or receiving face-to-face psychological treatment would also exclude the participants. Procedure Participants were recruited from eight child and adolescence psychiatric outpatient clinics. Information about the study was disseminated through meetings with clinic managers, emails to staff, and flyers placed in waiting rooms. Interested participants were provided with a link to the study website for information about the study and a brief preliminarily online screening. The online screening assessed three inclusion criteria: age, internet access, and language. In addition, participants were required to experience some form of disturbance in eating or eating-related behaviour that caused impairment or distress in daily life. This was assessed using selected items from the Norwegian version of the Eating Disorder Assessment for DSM-5 (EDA-5) ( 50 ). Eligible participants got the opportunity to leave their contact information and were contacted by telephone to validate the inclusion and exclusion criteria. A diagnostic assessment was conducted using EDA-5 ( 50 ) and The Mini international neuropsychiatric interview (MINI) ( 51 ). In response to slow recruitment, additional promotion of the study was carried out via upper secondary schools and advertisements on social media. As the study was conducted within routine clinical care, all participants had to be eligible for specialised care treatment in accordance with national priority guidelines ( 52 ). Participants who were not already patients at an outpatient clinic were required to visit their general practitioner (GP) to confirm medical stability and obtain a referral. Eligible participants were given access to the treatment (native) application where they had to sign consent forms, with those aged 15 years old required to provide additional parental consent. Development of the novel treatment The digital treatment was developed in line with The Person-Based Approach (PBA) ( 53 ). PBA is a methodological framework for how to understand the most effective way to apply appropriate behaviour change techniques in the specific context of the intervention and its intended users ( 53 ). In line with PBA, adolescents with lived experiences of eating disorders ( 26 ), mental health professionals and the existing evidence-base, helped us to identify key issues, needs, and challenges the intervention should address. Drawing on this in-depth understanding, key components were identified and systematically embedded into the design of the intervention. A logic model was created aiming to describe how the key components of the intervention should lead to positive behaviour change and better health (Fig. 1 Logic model). In the stage of development, the key components were incorporated and user-tested to refine the digital treatment to meet user requirements. This model serves as a background for the second aim of this study; exploring whether the following key components of the novel digital treatment align with the adolescents it is designed to support: eating disorders symptomatology, psychosocial impairment, emotional difficulties (emotion dysregulation, anxiety, and depression), negative self-evaluation, and motivational factors. Figure 1 Logic model Measures Data was collected using self-report questionnaires administrated online. Social demographic data (age, gender, living situation, engagement in school/with friends) were gathered using a questionnaire developed specifically for this study. In addition, the participants completed the following standardised measures, all previously used in eating disorder population ( 54 , 55 ): Eating Disorder Examination-Questionnaire Short (EDE-QS) Eating disorder symptoms was measured using the Eating Disorder Examination-Questionnaire Short (EDE-QS) ( 56 ). EDE-QS is a 12-item questionnaire with a 4-point response scale that assesses symptom severity over the preceding 7 days. Scores are ranging from 0 to 36 and higher scores indicate greater symptoms severity. A score of 15 or above serve as a cut-off point to distinguish between eating disorder cases and non-cases ( 57 ). The questionnaire has high internal consistency (Cronbach’s α = .91) ( 56 ). Clinical Impairment Assessment Questionnaire (CIA) Clinical Impairment Assessment Questionnaire (CIA) was used to assess the severity of psychosocial impairment due to eating disorder features ( 58 ). CIA consist of 16-items covering impairment in different domains of life that are typically affected by eating disorder psychopathology. Three sub-scales are computed representing personal, social and cognitive impairment that can result from eating disorders. Global scores range from 0 to 48, with higher ratings indicate a higher level of impairment ( 58 ). A global score of 16 or above represents a cut-off clinically significant impairment ( 58 ). Normative data from a clinical adult female sample in Norway have reported a mean score of 14.01 for the personal impartment subscale, 9.54 for the social impartment scale and 8.97 for the cognitive impairment subscale ( 59 ). In this study, the normative data have been rounded to the nearest whole number to report on the number of participants having a mean score that match the clinical sample. The questionnaire has high internal consistency (Cronbach’s α = 0.97) ( 58 ). Difficulties with Emotion Regulation Scale (DERS-18) The Difficulties with Emotion Regulation Scale (DERS-18) was used to assess clinically relevant difficulties in emotion regulation ( 60 ). Participants answer on a 5-point Likert-type scale ranging from 1 (almost never) to 5 (almost always). Scores range from 18–90, with higher scores indicate higher emotion dysregulation ( 60 ). DERS-18 consists of six subscales measuring difficulties in the flexible, multi-dimensional regulation of emotion: lack of awareness of one’s emotions (awareness), lack of acceptance of one’s emotions (nonacceptance), lack of access to effective emotion regulation strategies (strategies), lack of ability to manage one’s impulses during negative emotions (impulse), lack of ability to engage in goal-directed activities during negative emotions (goals), and lack of clarity about the nature of one’s emotions (clarity) ( 60 ). DERS-18’s internal consistency is very high (Cronbach's α = 0.90) ( 61 ). DERS is ideal for use in clinical research studies that require multiple assessment points, and is frequently used in treatment outcome research ( 61 ). Due to different versions of DERS it is difficult to collapse findings across studies ( 61 ). In one study from 2022 the DERS scores are organised by depression subgroups ( 62 ). For DERS-18 a total mean score of 35.88 = normal subgroup, 42.68 = mild depression, 48.39 = moderate depression, and 56.13 = severe depression ( 62 ). In this study we used the same putative depressive symptomatology subgroups to organise our samples level of difficulties with emotion regulation. We used the subgroup moderate depression as a cuff-off for difficulties within each domain. The number of reported cut-off scores have been rounded to the nearest whole number. Generalized Anxiety Disorder scale (GAD-2) Anxiety symptoms was measured using the two-item version of the Generalized Anxiety Disorder scale (GAD-2) ( 63 ). GAD-2 measures symptoms over the last two weeks scored on a four-point likert scale ranging from 0 “not at all” to 3 “nearly every day”, with a cutoff score of 3 or above ( 64 ). Patient Health Questionnaire (PHQ-2) Symptoms of depression was measured using the two-item version of the Patient Health Questionnaire (PHQ-2) ( 65 ). PHQ-2 measures symptoms over the last two weeks scored on a four-point likert scale ranging from 0 “not at all” to 3 “nearly every day” ( 66 ). PHQ-2’s standard cutoff score is ≥ 3, however a cutoff of ≥ 2 could be an optimal cutoff score for adolescents ( 67 ). Rosenberg Self-Esteem Scale (RSES) The Rosenberg Self-Esteem Scale (RSES) was used to measure negative self-evaluation ( 68 ). RSES measures self-competence and self-liking using ten items answered on a four-point Likert-type scale — from strongly agree to strongly disagree. The scale ranges from 0–30 and scores between 15 and 25 are within normal range; scores below 15 suggest low self-esteem ( 68 ). The questionnaires Cronbach's α = 0.92, indicating excellent internal consistency ( 68 ). Total burden of symptoms In order to assess the overall burden of the symptoms among the adolescents recruited to the novel digital treatment, a total burden of symptoms was computed (0–6). Each standardised measure exceeding its clinical cut-off contributes one point to the total symptom burden score; thus, a score of 1 indicates one measure above cut-off, a score of 2 indicates two measures above cut-off, and so forth. Treatment motivation In addition to the standardised measures, the participants were given a 6-item questionnaire to explore motivational factors for participating in a novel treatment. Due to lack of validated questionnaires, we developed the questionnaire specifically for this study. The questionnaire is inspired by the Short Motivation Feedback List ( 69 ) that are based on self-determination theory ( 70 ). The questionnaire consists of four 5-point Likert-scale items ranging from “Strongly disagree” to “Strongly agree,” designed to capture the level and type (external or internal) treatment motivation. In addition, the participants were asked to rank (0-100%) how much effort they would put into carrying out the treatment and if they would involve others when needed. Data analysis Data was analysed using the Statistical Package for the Social Sciences (SPSS) version 29. Given the descriptive nature of this study, data are presented in terms of frequencies, percentages, means and standard deviations. Results The characteristics of adolescents seeking digital treatment Recruitment Following 14 months of recruitment, baseline data was utilised for this study, as the project neared completion. A total of 641 individuals accessed the online screening portal (Figure 1) between Mach 2024 and May 2025. Of these, 577 individuals were ineligible due to uncomplete screening, too high or low age, low symptom severity or living outside the catchment area. In addition, 129 individuals met the criteria for the online screening, but could not be contacted as they did not leave their contact information. Of the 64 adolescents eligible for approach 11 were excluded as they were unable to reach or declined participations. Of the 53 adolescents contacted by telephone, 20 were excluded from the study due to age (n=10), a primary anorexia nervosa (n=4), receiving face-to-face psychological treatment (n=3), low symptom severity (n=2), or AFRID (n=1). After inclusion, 5 adolescents changed their mind regarding participating, 2 were unable to reach and 1 was excluded due to a medical condition. 25 adolescents completed the baseline screening and enrolled in the study. Social demographic characteristics All the participants were females (Table 1). The median age of the study sample was 16 years (SD = 0.87, range 15-18). Over half of the sample was living with both parents (60%). All the participants were engaged in school (100%), and almost all (96%) were engaged with friends on a regular basis. Table 1 Social demographic characteristics of adolescents seeking digital treatment (n=25) Variable Values, n (%) Gender Male Female Other gender identities 0 (0) 25 (100) 0 (0) Mean age 16.48 (SD=0.87) Living situation Both parents 50/50 residential One parent Alone Other living agreement 15 (60) 3 (12) 4 (16) 1 (4) 2 (8) Engaged in education (total) Reduced time Full-time 25 (100) 5 (20) 20 (80) Engaged with friends (total) Daily Weekly Monthly 24 (96) 6 (24) 11 (44) 7 (28) Diagnoses and history of present illness Most of the adolescents were at inclusion diagnosed with atypical anorexia nervosa (40%) with the second largest group being eating disorder, unspecified (28%) (Table 2). The rest of the sample was equally distributed between atypical bulimia nervosa (16%) and binge eating disorder (16%). The mean age of eating disorder onset was 13 years (SD = 1.68, range 9-16). Half of the adolescents had previously received face-to-face treatment for an eating disorder (52%). Table 2 Diagnoses and history of present illness of adolescents seeking digital treatment (n=25) Variable n (%) Diagnoses (inclusion) Atypical anorexia nervosa Atypical bulimia nervosa Binge eating disorder Eating disorder, unspecified 10 (40) 4 (16) 4 (16) 7 (28) Prior eating disorder treatment Yes No 13 (52) 12 (48) Mean age of disorder onset 13.00 (SD=1.68) Motivational factors The adolescents’ motivational factors for participating in a novel digital treatment are summarised in Table 3. Most of the adolescents’ responses to the items 1 and 3, were in the higher categories 4 (agree) and 5 (strongly agree), indicating high internal treatment motivation. When asked to rank (0-100%) how much effort they would put into carrying out the treatment the mean score was 83% ranging from 50-100% (SD = 14.34). Regards the involvement of others, the mean score was somewhat lower (52%) with a range from 0-100% (SD = 33.18). Table 3 Motivational factors among adolescents seeking digital treatment Items N Median n (%) n (%) n (%) n (%) n (%) How much do you agree with the following statements: Strongly disagree Disagree Neither disagree nor agree Agree Strongly agree 1 I am participating in treatment because I want to 25 5 1 (4) 1 (4) 10 (40) 13 (52) 2 I am participating in treatment because others think I should 25 3 1(4) 4 (16) 8 (32) 9 (36) 3 (12) 3 I am participating in treatment because it will help me live a better life 25 4 2 (8) 1 (4) 12 (48) 10 (40) 4 I am participating in treatment to avoid disappointing others 25 2 5 (20) 9 (36) 5 (20) 5 (20) 1 (4) Eating disorder symptoms The distribution of eating disorder symptoms was in the severe range with a mean score of 21.56 (EDE-QS) (57). See Table 4 for an overview of the distribution of symptoms, range, cut-off and mean. Psychosocial impairment The global impartment score was high 28.08 (CIA) (58) (Table 4). The impartment subscales show difficulties within both the personal, social and cognitive domains (59). Emotional difficulties To explore the adolescents’ emotional difficulties, emotion dysregulation and symptoms of anxiety and depression was assessed (Table 4). The samples abilities to regulate emotions indicates moderate to severe difficulties within this domain with a total mean score of 53.72 (DERS-18) (62). The adolescents had difficulties within all the six DERS-18 subscales. In addition, they reported anxiety symptoms above cuff-off (GAD-2 score = 3.44) (64). The mean score for depression was below (PHQ-2 score = 2.60) (66), however using an optimal cutoff score for adolescents of ≥2 the score was above (67). Negative self-evaluation To evaluate the sample's level of negative self-evaluation we measured the adolescents’ self-esteem (RSES mean score = 11.76) which were in the range indicating sever low self-esteem (68). Table 4 Distribution of e ating disorder symptoms, psychosocial impairment, emotional difficulties and negative self-evaluation (n=25) Measure Range Cut-off * Mean (SD) Eating Disorder Examination-Questionnaire Short (EDE-QS) Total score 8-33 n=21 21.56 (6.80) Clinical Impairment Assessment Questionnaire (CIA) Global score 8-47 n= 22 28.08 (10.71) Personal impairment 5-18 n=13 13.08 (3.89) Social impairment 1-15 n=9 7.80 (4.10) Cognitive impairment 2-14 n=10 7.20 (3.52) Difficulties with Emotion Regulation Scale (DERS-18) Total score 32-85 n=17 53.72 (13.92) Awareness 4-13 n=21 10.00 (2.48) Non-acceptance 3-15 n=18 8.92 (3.39) Strategies 3-15 n=11 7.24 (3.64) Impulse 3-15 n=15 7.52 (3.68) Goals 5-15 n=15 11.16 (2.88) Clarity 3-15 n=15 8.88 (2.86) Generalized Anxiety Disorder scale (GAD-2) Total score 1-6 n=17 3.44 (1.69) Patient Health Questionnaire (PHQ-2) Total score 0-6 n=20 2.60 (1.56) Rosenberg Self-Esteem Scale (RSES) Total score 0-28 n=19 11.76 (6.33) Note: In CIA subscales and DERS-18 normative data are used due to the lack of clinical valid cut-off scores (58, 62). Total burden of symptoms The total burden of symptoms was calculated (Figure 3). The response median scores ranged from 0 to 6 with a median score on 5 measures above cut-off. Alignment between key components and adolescents’ characteristics The second aim of this study was to explore whether the key components of the novel intervention (for details, see fig.1 Logic model) aligns with the characteristics of the adolescents recruited to this study. Table 5 shows an overview of the key components, the result from measuring these characteristics and an evaluation of the alignment. Table 5 Alignment between the key components of the digital treatment and the adolescents’ characteristics Key components Result Evaluation Alignment Eating disorders symptomatology Majority above clinical cut-off Indicates that the treatment targets core symptoms relevant to the population. Yes Impairment High level of global impartment Suggests the intervention’s focus on functioning is well-matched to the samples needs. Yes Emotional difficulties High levels of anxiety, depression and emotional dysregulation Supports the relevance of the treatment targeting emotional difficulties within all these domains. Yes Negative self-evaluation Severe low self-esteem Confirms the importance of components addressing self-image and self-worth. Yes Motivational factors High level of pre-treatment motivation Higher levels than anticipated. Variability across individuals suggests that tailored engagement strategies may still be necessary to optimise uptake and adherence. Partial Discussion This study examined the characteristics of adolescents seeking digital treatment for eating disorders within routine clinical care and explored whether the key components of the novel digital treatment aligned with the characteristics of the adolescents it is designed to support. Characteristics of adolescents seeking digital treatment for eating disorders Atypical anorexia nervosa was the most frequently assigned diagnosis which aligns with data from a Norwegian community-based prevalence study ( 9 ). Further, the adolescents’ distributions of eating disorder symptoms and psychosocial impairment are consistent with the diagnostic thresholds necessary for inclusion in this study. Moreover, their elevated levels of emotional difficulties and negative self-evaluation are in concordance with other studies examining these mechanisms among adolescents with eating disorders ( 71 – 73 ). Low self-esteem and mood intolerance are particularly pertinent in the adolescent age range ( 72 ) and anxiety and depression are the most prevalent comorbid disorders ( 73 ). The adolescents’ total burden of symptoms across domains emphasis the samples severity. The adolescents reported a high level of internal pre-treatment motivation. The strong internal motivation may be linked to the adolescents’ severe eating disorder symptoms ( 8 ) or that they are more likely to engage in the intervention due to being recruited via a self-selection option ( 74 ). Providing adolescents with a sense of control and agency in treatment decision-making may contribute to improved adherence to therapeutic interventions ( 34 ). None of the adolescents included in this study being boys, reflect the well-established gender discrepancies in the field of eating disorders ( 5 ). Stigma associated with disclosure of mental health issues and cultural perceptions that eating disorders are typically female disorders might influence help-seeking behaviours among adolescent boys ( 75 ). Moreover, although individuals that identify as transgender and non-binary are at particularly high risk for developing eating disorders ( 76 , 77 ), no participants in this study identified with a gender other than female. The results of this study highlight the presence of underrepresented groups within the adolescent population seeking treatment for eating disorders ( 16 , 75 , 77 ). The novel interventions alignment with the adolescents’ characteristics The samples distribution of eating disorder symptoms indicates that the treatment targets core symptoms relevant to the population. In addition, the intervention’s focus on functioning is well-matched to the adolescents needs. Moreover, the inclusion of a transdiagnostic sample aligns with the goal of the novel interventions to address the multifaceted and overlapping nature of these conditions. Based on the perspectives of adolescents with lived experiences of an eating disorder, emotional difficulties and negative self-evaluation were some of the key components embedded in the design of the digital treatment ( 26 ). The result from this study shows that the adolescents’ high levels of difficulties within these domains supports the relevance of the treatment addressing emotional dysregulation, anxiety, depression and self-worth. This match may indicate that the intervention is designed for the users and contexts in which it will be implemented. Furthermore, the adolescents’ levels of pre-treatment motivation were higher than anticipated when designing the novel intervention. Variability across the adolescents highlights that tailored engagement strategies may still be a necessary key component for optimising the digital treatment’s uptake and adherence. Clinical implications and future directions Half of the adolescents seeking digital treatment had previously received face-to-face treatment for an eating disorder. This emphasises the relevance of digital interventions to complement or extend traditional care, particularly for individuals who may not have experienced sufficient benefit from prior treatment. Moreover, the adolescents’ high level of internal pre-treatment motivation may suggest that digital treatment can also serve as a viable alternative to face-to-face approaches for some individuals. Suitable options to traditional eating disorder treatment are an urgent need, not only due to the existing treatment challenges but also to address future public healthcare concerns. A remarkable increase in eating disorders among adolescents since the beginning of the COVID-19 pandemic emphasises a real challenge for healthcare providers ( 4 , 78 , 79 ). Adolescents with anorexia nervosa and bulimia nervosa were excluded from participating due to somatic complications commonly associated with these diagnose. Given the high prevalence of adolescents who go untreated ( 10 ) future steps should be made to offer the intervention to adolescents with these disorders within routine clinical care. A potential solution involves combining digital treatment with periodic in-person medical evaluations. This would also address the needs of those who prefer face-to-face interventions but endorse the advantages of digital interventions (e.g., availability in times of need and their ability to address stigma associated with help-seeking) ( 33 ). Additionally, digital platforms offer opportunities to integrate tools for monitoring symptoms that may signal medical risk, thereby enhancing patient safety and clinical responsiveness. Although emotional difficulties are common in adolescents with eating disorders ( 71 – 73 ), these domains are not a primary focus in the first-line of eating disorder treatments ( 16 ). In the design of mental health technologies, a shift from a top-down approach to a user-driven process necessitates new models of behaviour change that move beyond traditional psychotherapy frameworks ( 80 ). The results from this study are in concordance with other studies address the importance of targeting emotional difficulties in treatment of eating disorders ( 28 ). The current findings, highlights the present needs to increase diversity of underrepresented groups participating in eating disorder treatment for adolescents ( 16 , 76 , 77 ). These aspects should be taken into consideration when recruiting to future treatment studies, employing culturally sensitive language and using culturally appropriate measures ( 16 , 76 , 77 ). Limitations This study has important limitations that needs to be addressed. Firstly, participants were recruited via self-selection option which could have introduced some biases; such that only those who report elevated symptoms, more motivation, or who already knew the content would align with their preferences were seeking the novel digital treatment. Secondly, it remains unclear whether the novel digital treatment aligns with all intended users which may affect its implementation and dissemination. Thirdly, it is unknown whether the novel intervention can be a viable alternative to face-to-face approaches for adolescents with anorexia nervosa and bulimia nervosa due to excluding them form the study. Lastly, a systematic reporting and evaluation of the co-design process is lacking. Even though it is reasonable to consider that user involvement in the design and development process from the start influence the adolescents’ characteristics being embedded in the design, we do not know whether it was the involvement of users at a particular phase or the continuous involvement across all phases of design that offers benefits to design research. Conclusion The findings from this study underscore the relevance of digital interventions to complement or extend traditional eating disorder care for adolescents. Furthermore, the findings highlight the importance of enhancing diversity among adolescents participating in digital eating disorder treatments, to ensure equitable access and representation. The findings emphasise the importance of designing digital treatments that are sensitive to normative biases and highlights the value of involving a diverse group of adolescents with lived experience of eating disorders in the design and development process from the start. In addition, this study highlights the importance of designing digital treatments that address the multifaceted nature of eating disorders and are tailored to the needs and preferences of a transdiagnostic population. Present findings are important insofar as they may inform that the key treatment components align with the characteristics of adolescents seeking digital treatment for eating disorders within routine clinical care. Results from the ongoing open feasibility trial will show if the adolescents’ experiences the novel digital treatment acceptable, credible and if the treatment reduce symptoms and increase life-scooping skills. Declarations Ethical approval and consent to participate This study was approved by The Regional Committees for Medical and Health Research Ethics in Norway (REC- 639031). In addition, the study was conducted in line with the Haukeland university hospital’s guidelines for ethics and privacy considerations. Consent for publication Not applicable. Availability of data and materials Data generated, analysed, and reported during the current study are not publicly available, but are available in a slightly shortened, de-identified form from the corresponding author on reasonable request. The protocol may be shared upon request. Competing interests The authors declare that they have no competing interests. Funding This research was funded by the Norwegian Research Council [NFR 331794]. Authors contributions GH: Formal analysis; investigation; methodology; project administration; writing – original draft. ESN: Conceptualization; investigation; project administration; writing – review and editing. IBE: Supervision; writing – review and editing. EMSE: Project administration; writing – review and editing. TN: Conceptualization; supervision; methodology; formal analysis; project administration; writing – review and editing. All authors approved the final manuscript. 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13:57:34","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":192531,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7556084/v1/50edaa4d553888d776c32247.html"},{"id":94397890,"identity":"e66c6cdf-ee19-4c3d-aeaf-bd4ffa348960","added_by":"auto","created_at":"2025-10-27 13:56:52","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":286903,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLogic model\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"HolgersenFigure1Logicmodel.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7556084/v1/982efcdc1970781e669a5147.jpg"},{"id":94398707,"identity":"c1a898ed-1f0d-4e1e-91dc-1eabd91bb183","added_by":"auto","created_at":"2025-10-27 13:57:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":66737,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRecruitment flowchart\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7556084/v1/0ffe033f798a248afe3ad38d.png"},{"id":94397317,"identity":"940ebc4e-a5ea-4c12-b1e6-05662aacffcb","added_by":"auto","created_at":"2025-10-27 13:56:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":19022,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTotal burden of symptoms above established cut-offs among adolescents seeking digital treatment (n=25)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: Each standardised measure exceeding its clinical cut-off contributes one point to the total symptom burden score. A score of 1 indicates one measure above cut-off, a score of 2 indicates two measures above cut-off, and so forth.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7556084/v1/79b830a35364ec4ae87432a6.png"},{"id":101296854,"identity":"6b321718-a7f9-48c9-8bc2-f7472fa3411f","added_by":"auto","created_at":"2026-01-28 09:21:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2054539,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7556084/v1/23b212d7-cbd2-476b-9d60-1b32645e7cfe.pdf"},{"id":94398389,"identity":"f64acdc6-bcbd-496f-82a7-3f59da3db3d5","added_by":"auto","created_at":"2025-10-27 13:57:03","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":117577,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 1 (pdf). Title of data:\u003cstrong\u003e \u003c/strong\u003eCONSORT 2010 checklist of information to include when reporting a pilot or feasibility trial\u003cstrong\u003e. \u003c/strong\u003eDescription of data: Reporting guidance for feasibility trails.\u003c/p\u003e","description":"","filename":"Additionalfile1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7556084/v1/f2bd7fed5f7df10e9e6a6699.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Examining the characteristics of adolescents recruited to a novel digital treatment for eating disorders. Baseline findings from an open feasibility trial","fulltext":[{"header":"Plain English summary","content":"\u003cp\u003eThis study looked at adolescents aged 15 to 18 who were starting a new digital treatment for eating disorders as part of regular healthcare. The goal was to better understand who chooses this kind of help and whether the treatment fits their needs. All 25 participants were girls, and half had already received face-to-face treatment before. They had different types of eating disorders and reported serious symptoms, emotional struggles, and low self-esteem. Many were highly motivated to get better.\u003c/p\u003e\n\u003cp\u003eThe findings show that digital treatments can be a useful addition to traditional care for adolescents with eating disorders. However, the study also points out that more should be done to include a wider range of young people in these treatments. This will help make sure that digital options are fair and suitable for everyone who needs them.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eEating disorders are a group of complex clinical conditions characterised by pathological concerns about shape and weight and disturbed eating and weight-control behaviours (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Impaired physical health, disrupted psychosocial functioning, and reduced life expectancy are some of the severe consequences of eating disorders (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The disorders are highly prevalent worldwide, especially in adolescents (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Several evidence-based treatments are available (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) with Family-based treatment (FBT) and Enhanced Cognitive Behaviour Therapy (CBT-E) having the strongest evidence-base (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite the disorders severity and the availability of evidence-based treatments, most individuals who meet the criteria for a clinical eating disorder do not seek help (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Consequently, eating disorders remain highly undetected and subsequently untreated (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) with help-seeking behaviours rates particularly low among adolescents (10%-20%) (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Individual barriers to help-seeking behaviour include poor mental health literacy, stigma surrounding eating disorders, denial of the disorder\u0026rsquo;s severity, as well as distorted body ideals enforced by social media (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Systemic factors contributing to the existing treatment gap are limited therapist availability, the cost of treatment, geographic isolation from available services, long waitlists, and poor eating disorder literacy among primary care providers (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Moreover, of those who seek help, a sustainable number do not respond to the treatments currently available (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). High drop-out rates (29\u0026ndash;73%) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and low remission rates (40\u0026ndash;50%) indicate that a substantial proportion continue to exhibit high levels of eating pathology at the end of treatment (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Other factors have also been reported to contribute to make eating disorders particularly challenging to treat. The disorders complex interplay of psychological, biological, and social factors (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), the underlying mechanisms being unknown (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) and the high psychiatric comorbidity (\u0026gt;\u0026thinsp;70%) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) could be some of the reasons. Furthermore, eating disorder treatments often have a categorical approach, despite diagnostic migration is common and diagnoses vary across individuals (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In addition, treatments often follow standardised protocols and manuals which do not account for unique individual factors influencing an eating disorder (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). As a result, individuals with eating disorders can feel alienated from treatment (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Given the abovementioned challenges with treatment for eating disorders, there is a pressing need to both improve access to existing evidence-based treatments and develop novel interventions that address the multifaceted nature of these conditions (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA promising approach is treatments delivered via computers or smartphones, often referred to as digital interventions or digital treatments (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The accessibility of these treatments positions them as a valuable component within the spectrum of services for eating disorders, particularly considering the numerous of barriers associated with traditional treatments (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Digital interventions can increase access to care and have demonstrated effectiveness for improving symptoms of eating disorders while also being cost-effective (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Although endorsing many of these advantages, most individuals with eating disorders still prefer face-to-face treatment (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Moreover, despite a growing evidence base, only a small proportion of existing digital interventions have been developed specifically for adolescents with eating disorders (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In addition, digital intervention also faces challenges related to uptake and engagement (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) where one contributing factor may be the expert-driven development processes that do not sufficiently reflect the preferences and goals of the intended users (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo address these challenges, there is a need to develop novel digital interventions for adolescents with eating disorders (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) based on the perspectives of those who will use them (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Tailoring interventions to adolescents' needs is particularly important, as excluding their voices may undermine the real-world relevance (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Simply adapting adult interventions is not sufficient, as adolescents require developmentally and age-appropriate considerations (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Moreover, since these interventions are not suitable or preferred by everyone (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) understanding the characteristics of those who engage with digital interventions can help clinicians determine who may benefit from these interventions (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) and reveal whether certain groups are underrepresented which in turn could indicate a need to adapt the intervention to better fit into the daily lives of the people who will use them (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Despite this there is a significant lack in the involvement of children and adolescents when developing digital treatments and little is known whether the interventions that are designed aligns with their needs (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe current study aimed to i) examine the characteristics of adolescents seeking digital treatment for eating disorders within routine clinical care and ii) explore whether the key components of the novel digital treatment align with the characteristics of the adolescents it is designed to support.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy setting and design\u003c/h2\u003e\u003cp\u003eAn open feasibility trial of a digital treatment for adolescents with eating disorders was conducted at the Haukeland University Hospital in Bergen, Norway (ClinicalTrials.gov: NCT06306586). Adolescents receiving the digital treatment were patients at child and adolescent psychiatric outpatient clinics serving both urban and rural areas within the catchment area of the Western Norway Regional Health Authority. These clinics serve a population of approximate 122 000 youth below 18 years (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe feasibility trail was aiming to assess feasibility aspects regarding the sample\u0026rsquo;s representativeness, adherence, acceptability, and preliminary efficacy. In accordance with feasibility trail design, no formal sample size calculation was conducted. To examine the characteristics of the adolescents and explore whether the novel intervention aligns with the population it is designed to support, this study utilised baseline data from participants included in the feasibility trail between March 2024 and May 2025. Results are reported in accordance with the Consolidated Standards of Reporting Trials (CONOSORT) guidelines for feasibility trials [see Additional file 1 for CONSORT checklist] (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eInclusion criteria\u003c/h2\u003e\u003cp\u003eThe following inclusion criteria were applied for the feasibility trail: (a) Diagnosed with atypical anorexia nervosa, atypical bulimia nervosa, binge eating disorder, or eating disorder, unspecified (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), (b) Age between 15 and 18 years, (c) Stable dose of medication for a co-morbid psychiatric disorder for six weeks, (d) Having a mobile phone with internet access, (e) Speaks and writes Norwegian.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eTo ensure the safety of participants during the feasibility testing of a novel digital treatment, individuals with anorexia nervosa and bulimia nervosa were excluded due to somatic complications commonly associated with these diagnose (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Patients with avoidant restrictive food intake disorders (AFRID) were also excluded since the clinical picture is different from the other eating disorders (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Further, having a co-morbid medical condition or disorder known to influence eating or weight (i.e., pregnancy, cancer), psychotic disorders, acute suicidality, substance abuse, substance dependence or severe depressive episode were exclusion criteria. Receiving inpatient treatment for a psychiatric disorder or receiving face-to-face psychological treatment would also exclude the participants.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eParticipants were recruited from eight child and adolescence psychiatric outpatient clinics. Information about the study was disseminated through meetings with clinic managers, emails to staff, and flyers placed in waiting rooms. Interested participants were provided with a link to the study website for information about the study and a brief preliminarily online screening. The online screening assessed three inclusion criteria: age, internet access, and language. In addition, participants were required to experience some form of disturbance in eating or eating-related behaviour that caused impairment or distress in daily life. This was assessed using selected items from the Norwegian version of the Eating Disorder Assessment for DSM-5 (EDA-5) (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Eligible participants got the opportunity to leave their contact information and were contacted by telephone to validate the inclusion and exclusion criteria. A diagnostic assessment was conducted using EDA-5 (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) and The Mini international neuropsychiatric interview (MINI) (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). In response to slow recruitment, additional promotion of the study was carried out via upper secondary schools and advertisements on social media. As the study was conducted within routine clinical care, all participants had to be eligible for specialised care treatment in accordance with national priority guidelines (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Participants who were not already patients at an outpatient clinic were required to visit their general practitioner (GP) to confirm medical stability and obtain a referral. Eligible participants were given access to the treatment (native) application where they had to sign consent forms, with those aged 15 years old required to provide additional parental consent.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDevelopment of the novel treatment\u003c/h2\u003e\u003cp\u003eThe digital treatment was developed in line with The Person-Based Approach (PBA) (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). PBA is a methodological framework for how to understand the most effective way to apply appropriate behaviour change techniques in the specific context of the intervention and its intended users (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). In line with PBA, adolescents with lived experiences of eating disorders (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), mental health professionals and the existing evidence-base, helped us to identify key issues, needs, and challenges the intervention should address. Drawing on this in-depth understanding, key components were identified and systematically embedded into the design of the intervention. A logic model was created aiming to describe how the key components of the intervention should lead to positive behaviour change and better health (Fig.\u0026nbsp;1 Logic model). In the stage of development, the key components were incorporated and user-tested to refine the digital treatment to meet user requirements. This model serves as a background for the second aim of this study; exploring whether the following key components of the novel digital treatment align with the adolescents it is designed to support: eating disorders symptomatology, psychosocial impairment, emotional difficulties (emotion dysregulation, anxiety, and depression), negative self-evaluation, and motivational factors.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFigure 1 Logic model\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eData was collected using self-report questionnaires administrated online. Social demographic data (age, gender, living situation, engagement in school/with friends) were gathered using a questionnaire developed specifically for this study. In addition, the participants completed the following standardised measures, all previously used in eating disorder population (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e):\u003c/p\u003e\n\u003ch3\u003eEating Disorder Examination-Questionnaire Short (EDE-QS)\u003c/h3\u003e\n\u003cp\u003eEating disorder symptoms was measured using the Eating Disorder Examination-Questionnaire Short (EDE-QS) (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). EDE-QS is a 12-item questionnaire with a 4-point response scale that assesses symptom severity over the preceding 7 days. Scores are ranging from 0 to 36 and higher scores indicate greater symptoms severity. A score of 15 or above serve as a cut-off point to distinguish between eating disorder cases and non-cases (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). The questionnaire has high internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.91) (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eClinical Impairment Assessment Questionnaire (CIA)\u003c/h2\u003e\u003cp\u003eClinical Impairment Assessment Questionnaire (CIA) was used to assess the severity of psychosocial impairment due to eating disorder features (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). CIA consist of 16-items covering impairment in different domains of life that are typically affected by eating disorder psychopathology. Three sub-scales are computed representing personal, social and cognitive impairment that can result from eating disorders. Global scores range from 0 to 48, with higher ratings indicate a higher level of impairment (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). A global score of 16 or above represents a cut-off clinically significant impairment (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). Normative data from a clinical adult female sample in Norway have reported a mean score of 14.01 for the personal impartment subscale, 9.54 for the social impartment scale and 8.97 for the cognitive impairment subscale (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). In this study, the normative data have been rounded to the nearest whole number to report on the number of participants having a mean score that match the clinical sample. The questionnaire has high internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.97) (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eDifficulties with Emotion Regulation Scale (DERS-18)\u003c/h2\u003e\u003cp\u003eThe Difficulties with Emotion Regulation Scale (DERS-18) was used to assess clinically relevant difficulties in emotion regulation (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). Participants answer on a 5-point Likert-type scale ranging from 1 (almost never) to 5 (almost always). Scores range from 18\u0026ndash;90, with higher scores indicate higher emotion dysregulation (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). DERS-18 consists of six subscales measuring difficulties in the flexible, multi-dimensional regulation of emotion: lack of awareness of one\u0026rsquo;s emotions (awareness), lack of acceptance of one\u0026rsquo;s emotions (nonacceptance), lack of access to effective emotion regulation strategies (strategies), lack of ability to manage one\u0026rsquo;s impulses during negative emotions (impulse), lack of ability to engage in goal-directed activities during negative emotions (goals), and lack of clarity about the nature of one\u0026rsquo;s emotions (clarity) (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). DERS-18\u0026rsquo;s internal consistency is very high (Cronbach's α\u0026thinsp;=\u0026thinsp;0.90) (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). DERS is ideal for use in clinical research studies that require multiple assessment points, and is frequently used in treatment outcome research (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). Due to different versions of DERS it is difficult to collapse findings across studies (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). In one study from 2022 the DERS scores are organised by depression subgroups (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e). For DERS-18 a total mean score of 35.88\u0026thinsp;=\u0026thinsp;normal subgroup, 42.68\u0026thinsp;=\u0026thinsp;mild depression, 48.39\u0026thinsp;=\u0026thinsp;moderate depression, and 56.13\u0026thinsp;=\u0026thinsp;severe depression (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e). In this study we used the same putative depressive symptomatology subgroups to organise our samples level of difficulties with emotion regulation. We used the subgroup moderate depression as a cuff-off for difficulties within each domain. The number of reported cut-off scores have been rounded to the nearest whole number.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eGeneralized Anxiety Disorder scale (GAD-2)\u003c/h2\u003e\u003cp\u003eAnxiety symptoms was measured using the two-item version of the Generalized Anxiety Disorder scale (GAD-2) (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). GAD-2 measures symptoms over the last two weeks scored on a four-point likert scale ranging from 0 \u0026ldquo;not at all\u0026rdquo; to 3 \u0026ldquo;nearly every day\u0026rdquo;, with a cutoff score of 3 or above (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003ePatient Health Questionnaire (PHQ-2)\u003c/h2\u003e\u003cp\u003eSymptoms of depression was measured using the two-item version of the Patient Health Questionnaire (PHQ-2) (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). PHQ-2 measures symptoms over the last two weeks scored on a four-point likert scale ranging from 0 \u0026ldquo;not at all\u0026rdquo; to 3 \u0026ldquo;nearly every day\u0026rdquo; (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). PHQ-2\u0026rsquo;s standard cutoff score is \u0026ge;\u0026thinsp;3, however a cutoff of \u0026ge;\u0026thinsp;2 could be an optimal cutoff score for adolescents (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eRosenberg Self-Esteem Scale (RSES)\u003c/h2\u003e\u003cp\u003eThe Rosenberg Self-Esteem Scale (RSES) was used to measure negative self-evaluation (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). RSES measures self-competence and self-liking using ten items answered on a four-point Likert-type scale \u0026mdash; from strongly agree to strongly disagree. The scale ranges from 0\u0026ndash;30 and scores between 15 and 25 are within normal range; scores below 15 suggest low self-esteem (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). The questionnaires Cronbach's α\u0026thinsp;=\u0026thinsp;0.92, indicating excellent internal consistency (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eTotal burden of symptoms\u003c/h2\u003e\u003cp\u003eIn order to assess the overall burden of the symptoms among the adolescents recruited to the novel digital treatment, a total burden of symptoms was computed (0\u0026ndash;6). Each standardised measure exceeding its clinical cut-off contributes one point to the total symptom burden score; thus, a score of 1 indicates one measure above cut-off, a score of 2 indicates two measures above cut-off, and so forth.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eTreatment motivation\u003c/h2\u003e\u003cp\u003eIn addition to the standardised measures, the participants were given a 6-item questionnaire to explore motivational factors for participating in a novel treatment. Due to lack of validated questionnaires, we developed the questionnaire specifically for this study. The questionnaire is inspired by the Short Motivation Feedback List (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e) that are based on self-determination theory (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e). The questionnaire consists of four 5-point Likert-scale items ranging from \u0026ldquo;Strongly disagree\u0026rdquo; to \u0026ldquo;Strongly agree,\u0026rdquo; designed to capture the level and type (external or internal) treatment motivation. In addition, the participants were asked to rank (0-100%) how much effort they would put into carrying out the treatment and if they would involve others when needed.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eData was analysed using the Statistical Package for the Social Sciences (SPSS) version 29. Given the descriptive nature of this study, data are presented in terms of frequencies, percentages, means and standard deviations.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eThe characteristics\u0026nbsp;of adolescents seeking digital treatment\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing 14 months of recruitment, baseline data was utilised for this study, as the project neared completion. A total of 641 individuals accessed the online screening portal (Figure 1) between Mach 2024 and May 2025. Of these, 577 individuals were ineligible due to uncomplete screening, too high or low age, low symptom severity or living outside the catchment area. In addition, 129 individuals met the criteria for the online screening, but could not be contacted as they did not leave their contact information. Of the 64 adolescents eligible for approach 11 were excluded as they were unable to reach or declined participations. Of the 53 adolescents contacted by telephone, 20 were excluded from the study due to age (n=10), a primary anorexia nervosa (n=4), receiving face-to-face psychological treatment (n=3), low symptom severity (n=2), or AFRID (n=1). \u0026nbsp;After inclusion, 5 adolescents changed their mind regarding participating, 2 were unable to reach and 1 was excluded due to a medical condition. 25 adolescents completed the baseline screening and enrolled in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocial demographic characteristics\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All the participants were females (Table 1). The median age of the study sample was 16 years (SD\u0026thinsp;=\u0026thinsp;0.87, range 15-18). Over half of the sample was living with both parents (60%). All the participants were engaged in school (100%), and almost all (96%) were engaged with friends on a regular basis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Table 1 Social demographic characteristics of adolescents seeking digital treatment (n=25)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValues, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eOther gender identities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003cp\u003e25 (100)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e16.48 (SD=0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiving situation\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Both parents\u0026nbsp;\u003cbr\u003e\u0026nbsp;50/50 residential\u003c/p\u003e\n \u003cp\u003eOne parent\u003c/p\u003e\n \u003cp\u003eAlone\u003c/p\u003e\n \u003cp\u003eOther living agreement\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (60)\u003c/p\u003e\n \u003cp\u003e3 (12)\u003c/p\u003e\n \u003cp\u003e4 (16)\u003c/p\u003e\n \u003cp\u003e1 (4)\u003c/p\u003e\n \u003cp\u003e2 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEngaged in education\u0026nbsp;\u003c/strong\u003e(total)\u003c/p\u003e\n \u003cp\u003eReduced time\u003c/p\u003e\n \u003cp\u003eFull-time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e25 (100)\u003c/p\u003e\n \u003cp\u003e5 (20)\u003c/p\u003e\n \u003cp\u003e20 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEngaged with friends\u0026nbsp;\u003c/strong\u003e(total)\u003c/p\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003cp\u003eWeekly\u003c/p\u003e\n \u003cp\u003eMonthly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e24 (96)\u003c/p\u003e\n \u003cp\u003e6 (24)\u003c/p\u003e\n \u003cp\u003e11 (44)\u003c/p\u003e\n \u003cp\u003e7 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Diagnoses and history of present illness\u003cbr\u003e\u003c/strong\u003eMost of the adolescents were at inclusion diagnosed with atypical anorexia nervosa (40%) with the second largest group being eating disorder, unspecified (28%) (Table 2). The rest of the sample was equally distributed between atypical bulimia nervosa (16%) and binge eating disorder (16%). The mean age of eating disorder onset was 13 years (SD = 1.68, range 9-16). Half of the adolescents had previously received face-to-face treatment for an eating disorder (52%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e \u003cstrong\u003eDiagnoses and history of present illness\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eof adolescents seeking digital treatment (n=25)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnoses\u0026nbsp;\u003c/strong\u003e(inclusion)\u003c/p\u003e\n \u003cp\u003eAtypical anorexia nervosa\u0026nbsp;\u003cbr\u003e\u0026nbsp;Atypical bulimia nervosa\u003cbr\u003e\u0026nbsp;Binge eating disorder\u003c/p\u003e\n \u003cp\u003eEating disorder, unspecified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (40)\u003c/p\u003e\n \u003cp\u003e4 (16)\u003cbr\u003e\u0026nbsp;4 (16)\u003c/p\u003e\n \u003cp\u003e7 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrior eating disorder treatment\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (52)\u003cbr\u003e\u0026nbsp;12 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age of disorder onset\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e13.00 (SD=1.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Motivational factors\u003cbr\u003e\u003c/strong\u003eThe adolescents\u0026rsquo; motivational factors for participating in a novel digital treatment are summarised in\u0026nbsp;Table 3. Most of the adolescents\u0026rsquo; responses to the items 1 and 3, were in the higher categories 4 (agree) and 5 (strongly agree), indicating high internal treatment motivation. When asked to rank (0-100%) how much effort they would put into carrying out the treatment the mean score was 83% ranging from 50-100% (SD = 14.34). Regards the involvement of others, the mean score was somewhat lower (52%) with a range from 0-100% (SD = 33.18).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 Motivational factors\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eamong adolescents seeking digital treatment\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItems\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eHow much do you agree with the following statements:\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eStrongly disagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eDisagree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eNeither disagree\u0026nbsp;\u003cbr\u003e\u0026nbsp;nor agree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eAgree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eStrongly agree\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eI am participating in treatment because I want to\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e10 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e13 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eI am participating in treatment because others think I should\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1(4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e8 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e9 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eI am participating in treatment because it will help me live a better life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e12 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e10 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eI am participating in treatment to avoid disappointing others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e5 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e9 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5\u0026nbsp;(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e5 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Eating disorder symptoms\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eThe distribution of eating disorder symptoms was in the severe range with a mean score of 21.56 (EDE-QS) (57). See Table 4 for an overview of the distribution of symptoms, range, cut-off and mean.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePsychosocial impairment\u003cbr\u003e\u003c/strong\u003eThe global impartment score was high 28.08 (CIA) (58) (Table 4). The impartment subscales show difficulties within both the personal, social and cognitive domains (59).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEmotional difficulties\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eTo explore the\u0026nbsp;adolescents\u0026rsquo;\u0026nbsp;emotional difficulties, emotion dysregulation and symptoms of anxiety and depression was assessed (Table 4).\u0026nbsp;The samples abilities to regulate emotions\u0026nbsp;indicates moderate to severe difficulties within this domain with a total mean score of 53.72 (DERS-18) (62). The adolescents had difficulties\u0026nbsp;within all the six DERS-18 subscales. In addition, they\u0026nbsp;reported\u0026nbsp;anxiety symptoms\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eabove cuff-off (GAD-2 score = 3.44) (64). The mean score for depression was below (PHQ-2 score = 2.60) (66), however using an optimal cutoff score for adolescents of \u0026ge;2 the score was above (67).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNegative self-evaluation\u003cbr\u003e\u003c/strong\u003eTo evaluate\u0026nbsp;the sample\u0026apos;s level of negative self-evaluation we measured the adolescents\u0026rsquo; self-esteem\u0026nbsp;(RSES mean score = 11.76) which were in the range indicating sever low self-esteem (68).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e \u003cstrong\u003eDistribution of e\u003c/strong\u003e\u003cstrong\u003eating disorder symptoms, psychosocial impairment, emotional difficulties\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and negative self-evaluation (n=25)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeasure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCut-off\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEating Disorder Examination-Questionnaire Short (EDE-QS)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e8-33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21.56 (6.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Impairment Assessment Questionnaire (CIA)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eGlobal score\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e8-47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en= 22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e28.08 (10.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003ePersonal impairment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e5-18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13.08 (3.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eSocial impairment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7.80 (4.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eCognitive impairment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2-14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7.20 (3.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifficulties with Emotion Regulation Scale (DERS-18)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e32-85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e53.72 (13.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eAwareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e4-13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10.00 (2.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eNon-acceptance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8.92 (3.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eStrategies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7.24 (3.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eImpulse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7.52 (3.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eGoals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e5-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e11.16 (2.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eClarity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8.88 (2.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneralized Anxiety Disorder scale (GAD-2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3.44 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient Health Questionnaire (PHQ-2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eTotal score\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.60 (1.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRosenberg Self-Esteem Scale (RSES)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0-28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003en=19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e11.76 (6.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 614px;\"\u003e\n \u003cp\u003e\u003cem\u003eNote: In CIA subscales and DERS-18 normative data are used due to the lack of clinical valid cut-off scores (58, 62).\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTotal burden of symptoms\u003cbr\u003e\u003c/strong\u003eThe total burden of symptoms was calculated (Figure 3). The response median scores ranged from 0 to 6 with a median score on 5 measures above cut-off.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Alignment between key components and adolescents\u0026rsquo; characteristics\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThe second aim of this study was to explore whether the key components of the novel intervention (for details, see fig.1 Logic model) aligns with the characteristics of the adolescents recruited to this study. Table 5 shows an overview of the key components, the result from measuring these characteristics and an evaluation of the alignment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5 Alignment between the key components\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;of the digital treatment and the adolescents\u0026rsquo; characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey components\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResult\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEvaluation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlignment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eEating disorders symptomatology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMajority above clinical cut-off\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eIndicates that the treatment targets core symptoms relevant to the population.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eImpairment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eHigh level of global impartment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eSuggests the intervention\u0026rsquo;s focus on functioning is well-matched to the samples needs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eEmotional difficulties\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eHigh levels of anxiety, depression and emotional dysregulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eSupports the relevance of the treatment targeting emotional difficulties within all these domains.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNegative\u0026nbsp;\u003cbr\u003e\u0026nbsp;self-evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eSevere low self-esteem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eConfirms the importance of components addressing self-image and self-worth.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eMotivational factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eHigh level of\u003cbr\u003e\u0026nbsp;pre-treatment motivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eHigher levels than anticipated. Variability across individuals suggests that tailored engagement strategies may still be necessary to optimise uptake and adherence.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003ePartial\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the characteristics of adolescents seeking digital treatment for eating disorders within routine clinical care and explored whether the key components of the novel digital treatment aligned with the characteristics of the adolescents it is designed to support.\u003c/p\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eCharacteristics of adolescents seeking digital treatment for eating disorders\u003c/h2\u003e\u003cp\u003eAtypical anorexia nervosa was the most frequently assigned diagnosis which aligns with data from a Norwegian community-based prevalence study (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Further, the adolescents\u0026rsquo; distributions of eating disorder symptoms and psychosocial impairment are consistent with the diagnostic thresholds necessary for inclusion in this study. Moreover, their elevated levels of emotional difficulties and negative self-evaluation are in concordance with other studies examining these mechanisms among adolescents with eating disorders (\u003cspan additionalcitationids=\"CR72\" citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e). Low self-esteem and mood intolerance are particularly pertinent in the adolescent age range (\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e) and anxiety and depression are the most prevalent comorbid disorders (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e). The adolescents\u0026rsquo; total burden of symptoms across domains emphasis the samples severity.\u003c/p\u003e\u003cp\u003eThe adolescents reported a high level of internal pre-treatment motivation. The strong internal motivation may be linked to the adolescents\u0026rsquo; severe eating disorder symptoms (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) or that they are more likely to engage in the intervention due to being recruited via a self-selection option (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). Providing adolescents with a sense of control and agency in treatment decision-making may contribute to improved adherence to therapeutic interventions (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNone of the adolescents included in this study being boys, reflect the well-established gender discrepancies in the field of eating disorders (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Stigma associated with disclosure of mental health issues and cultural perceptions that eating disorders are typically female disorders might influence help-seeking behaviours among adolescent boys (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e). Moreover, although individuals that identify as transgender and non-binary are at particularly high risk for developing eating disorders (\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e), no participants in this study identified with a gender other than female. The results of this study highlight the presence of underrepresented groups within the adolescent population seeking treatment for eating disorders (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\u003ch2\u003eThe novel interventions alignment with the adolescents\u0026rsquo; characteristics\u003c/h2\u003e\u003cp\u003eThe samples distribution of eating disorder symptoms indicates that the treatment targets core symptoms relevant to the population. In addition, the intervention\u0026rsquo;s focus on functioning is well-matched to the adolescents needs. Moreover, the inclusion of a transdiagnostic sample aligns with the goal of the novel interventions to address the multifaceted and overlapping nature of these conditions. Based on the perspectives of adolescents with lived experiences of an eating disorder, emotional difficulties and negative self-evaluation were some of the key components embedded in the design of the digital treatment (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The result from this study shows that the adolescents\u0026rsquo; high levels of difficulties within these domains supports the relevance of the treatment addressing emotional dysregulation, anxiety, depression and self-worth. This match may indicate that the intervention is designed for the users and contexts in which it will be implemented. Furthermore, the adolescents\u0026rsquo; levels of pre-treatment motivation were higher than anticipated when designing the novel intervention. Variability across the adolescents highlights that tailored engagement strategies may still be a necessary key component for optimising the digital treatment\u0026rsquo;s uptake and adherence.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec34\" class=\"Section3\"\u003e\u003ch2\u003eClinical implications and future directions\u003c/h2\u003e\u003cp\u003eHalf of the adolescents seeking digital treatment had previously received face-to-face treatment for an eating disorder. This emphasises the relevance of digital interventions to complement or extend traditional care, particularly for individuals who may not have experienced sufficient benefit from prior treatment. Moreover, the adolescents\u0026rsquo; high level of internal pre-treatment motivation may suggest that digital treatment can also serve as a viable alternative to face-to-face approaches for some individuals. Suitable options to traditional eating disorder treatment are an urgent need, not only due to the existing treatment challenges but also to address future public healthcare concerns. A remarkable increase in eating disorders among adolescents since the beginning of the COVID-19 pandemic emphasises a real challenge for healthcare providers (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAdolescents with anorexia nervosa and bulimia nervosa were excluded from participating due to somatic complications commonly associated with these diagnose. Given the high prevalence of adolescents who go untreated (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) future steps should be made to offer the intervention to adolescents with these disorders within routine clinical care. A potential solution involves combining digital treatment with periodic in-person medical evaluations. This would also address the needs of those who prefer face-to-face interventions but endorse the advantages of digital interventions (e.g., availability in times of need and their ability to address stigma associated with help-seeking) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Additionally, digital platforms offer opportunities to integrate tools for monitoring symptoms that may signal medical risk, thereby enhancing patient safety and clinical responsiveness.\u003c/p\u003e\u003cp\u003eAlthough emotional difficulties are common in adolescents with eating disorders (\u003cspan additionalcitationids=\"CR72\" citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e), these domains are not a primary focus in the first-line of eating disorder treatments (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In the design of mental health technologies, a shift from a top-down approach to a user-driven process necessitates new models of behaviour change that move beyond traditional psychotherapy frameworks (\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e). The results from this study are in concordance with other studies address the importance of targeting emotional difficulties in treatment of eating disorders (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe current findings, highlights the present needs to increase diversity of underrepresented groups participating in eating disorder treatment for adolescents (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e). These aspects should be taken into consideration when recruiting to future treatment studies, employing culturally sensitive language and using culturally appropriate measures (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis study has important limitations that needs to be addressed. Firstly, participants were recruited via self-selection option which could have introduced some biases; such that only those who report elevated symptoms, more motivation, or who already knew the content would align with their preferences were seeking the novel digital treatment. Secondly, it remains unclear whether the novel digital treatment aligns with all intended users which may affect its implementation and dissemination. Thirdly, it is unknown whether the novel intervention can be a viable alternative to face-to-face approaches for adolescents with anorexia nervosa and bulimia nervosa due to excluding them form the study. Lastly, a systematic reporting and evaluation of the co-design process is lacking. Even though it is reasonable to consider that user involvement in the design and development process from the start influence the adolescents\u0026rsquo; characteristics being embedded in the design, we do not know whether it was the involvement of users at a particular phase or the continuous involvement across all phases of design that offers benefits to design research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings from this study underscore the relevance of digital interventions to complement or extend traditional eating disorder care for adolescents. Furthermore, the findings highlight the importance of enhancing diversity among adolescents participating in digital eating disorder treatments, to ensure equitable access and representation. The findings emphasise the importance of designing digital treatments that are sensitive to normative biases and highlights the value of involving a diverse group of adolescents with lived experience of eating disorders in the design and development process from the start. In addition, this study highlights the importance of designing digital treatments that address the multifaceted nature of eating disorders and are tailored to the needs and preferences of a transdiagnostic population. Present findings are important insofar as they may inform that the key treatment components align with the characteristics of adolescents seeking digital treatment for eating disorders within routine clinical care. Results from the ongoing open feasibility trial will show if the adolescents\u0026rsquo; experiences the novel digital treatment acceptable, credible and if the treatment reduce symptoms and increase life-scooping skills.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003cbr\u003e\u003c/strong\u003eThis study was approved by The Regional Committees for Medical and Health Research Ethics in Norway (REC- 639031). In addition, the study was conducted in line with the Haukeland university hospital\u0026rsquo;s guidelines for ethics and privacy considerations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003cbr\u003e\u003c/strong\u003eData generated, analysed, and reported during the current study are not publicly available, but are available in a slightly shortened, de-identified form from the corresponding author on reasonable request. The protocol may be shared upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003cbr\u003e\u003c/strong\u003eThis research was funded by the Norwegian Research Council [NFR 331794].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003cbr\u003e \u003cem\u003eGH:\u003c/em\u003e\u003c/strong\u003e Formal analysis; investigation; methodology; project administration; writing \u0026ndash; original draft.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003eESN:\u003c/em\u003e\u003c/strong\u003e Conceptualization; investigation; project administration; writing \u0026ndash; review and editing.\u0026nbsp;\u003cstrong\u003e\u003cem\u003eIBE:\u003c/em\u003e\u0026nbsp;\u003c/strong\u003eSupervision; writing \u0026ndash; review and editing.\u0026nbsp;\u003cstrong\u003e\u003cem\u003eEMSE:\u003c/em\u003e\u003c/strong\u003e Project administration; writing \u0026ndash; review and editing.\u0026nbsp;\u003cstrong\u003e\u003cem\u003eTN:\u003c/em\u003e\u003c/strong\u003e Conceptualization; supervision; methodology; formal analysis; project administration; writing \u0026ndash; review and editing. All authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003cbr\u003e\u003c/strong\u003eThe authors wish to thank the adolescents who generously participated in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEditorial note on language assistance\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eThis manuscript includes sentences that were edited with the assistance of a large language model (Microsoft 365 Copilot Chat) to improve clarity and grammar. In addition, the model was used to support the writing of the \u0026ldquo;Plain English Summary\u0026rdquo;, ensuring accessibility for individuals with lived experience and the wider public.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health O. 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Z Kinder Jugendpsychiatr Psychother. 2020;48(1):25-32.\u003c/li\u003e\n\u003cli\u003eGorrell S, Murray SB. Eating Disorders in Males. Child and Adolescent Psychiatric Clinics of North America. 2019;28(4):641-51.\u003c/li\u003e\n\u003cli\u003eSpringmann M-L, Svaldi J, Kiegelmann M. Theoretical and Methodological Considerations for Research on Eating Disorders and Gender. Frontiers in Psychology. 2020;Volume 11 - 2020.\u003c/li\u003e\n\u003cli\u003eGoldhammer HB, Maston ED, Keuroghlian AS. Addressing Eating Disorders and Body Dissatisfaction in Sexual and Gender Minority Youth. American Journal of Preventive Medicine. 2019;56(2):318-22.\u003c/li\u003e\n\u003cli\u003eMadigan S, Vaillancourt T, Dimitropoulos G, Premji S, Kahlert SM, Zumwalt K, et al. A Systematic Review and Meta-Analysis: Child and Adolescent Healthcare Utilization for Eating Disorders During the COVID-19 Pandemic. Journal of the American Academy of Child \u0026amp; Adolescent Psychiatry. 2025;64(2):158-71.\u003c/li\u003e\n\u003cli\u003ePastore M, Indrio F, Bali D, Vural M, Giardino I, Pettoello-Mantovani M. Alarming Increase of Eating Disorders in Children and Adolescents. The Journal of Pediatrics. 2023;263.\u003c/li\u003e\n\u003cli\u003eMohr DC, Weingardt KR, Reddy M, Schueller S. Three Problems With Current Digital Mental Health Research . . . and Three Things We Can Do About Them. Psychiatric Services. 2017;68(5):427-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"eating disorders, adolescents, transdiagnostic, digital treatment, routine clinical care, developing novel intervention, characteristics of help-seeking","lastPublishedDoi":"10.21203/rs.3.rs-7556084/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7556084/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDigital interventions for eating disorders have the potential to increase access to care and broaden the range of treatment options for adolescents. However, little is known about the characteristics of those who seek these interventions. Identifying such characteristics will help to ensure that these interventions meet the needs in the target population, highlight potential unrepresented groups, and support clinicians in assessing clinical suitability for individual patients. This study aimed to i) examine the characteristics of adolescents seeking digital treatment for eating disorders within routine clinical care and ii) explore whether the key components of the novel digital treatment align with the characteristics of the adolescents it is designed to support.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis study utilised baseline data from an open feasibility trial of a novel digital treatment for eating disorders within routine clinical care. Participants were adolescents aged 15\u0026ndash;18 years, with a diagnosis of atypical anorexia nervosa, atypical bulimia nervosa, binge eating disorder, or eating disorder, unspecified. Baseline assessment included: Demographic characteristics, eating disorders symptomatology, psychosocial impairment, emotional dysregulation, anxiety, depression, negative self-evaluation, and motivational factors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 25 adolescent participated in the study, only female. Mean age was 16 years. Half of the adolescents had previously received face-to-face treatment for an eating disorder. The sample was transdiagnostic with some variation in distribution. The adolescents reported severe eating disorder symptoms, marked psychosocial impairment, emotional difficulties, elevated negative self-evaluation and high levels of internal pre-treatment motivation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe findings from this study underscore the relevance of digital interventions to complement or extend traditional eating disorder care for adolescents. This study emphasises the importance of designing digital treatments that are sensitive to normative biases, address the multifaceted nature of eating disorders and are tailored to the needs and preferences of a transdiagnostic population. Present findings are important insofar as they may inform that the key treatment components align with the characteristics of adolescents seeking digital treatment for eating disorders within routine clinical care.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e\u003cp\u003eClinicalTrials.gov NCT06306586. Approved 05.03.2024. Available online 12.03.2024.\u003c/p\u003e","manuscriptTitle":"Examining the characteristics of adolescents recruited to a novel digital treatment for eating disorders. 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