Background: The gamification of behavioral intervention for tic disorders (TDs) may not only enhance compliance with treatment protocols but also offer a key clinical advantage. By providing immediate positive feedback when tics are suppressed, games can counteract negative reinforcement processes that reinforce tics, which assumingly alleviates unpleasant premonitory urges. We developed a gamified protocol (XTics), which leverages this potential by combining gamified tic triggers with immediate reinforcement of tic suppression. We evaluate the clinical value of immediate reward contingency in enhancing tic suppression performance. Methods: XTics comprises two conditions: tic-contingent and non-contingent. In the tic-contingent version, game progression was determined by real-time input from an experimenter who monitored the participant's tics, rewarding tic suppression with favorable outcomes. Conversely, in the non-contingent version, game events occurred randomly. Using a crossover design, we trained 35 participants (aged 7-15) in both versions, with each participant undergoing a preliminary behavioral training and three hourly sessions for each condition. We Page 2 both evaluated the overall protocol's four-week impact on tic severity measures and compared contingent and non-contingent conditions. Results: We achieved complete adherence to the protocol, while the participants increased their tic-free intervals by an average of 558% from the first to the last training day. YGTSS, a clinical measure of tic severity, showed an average clinically meaningful reduction of 25.69±23.39%, which was larger than that observed in control interventions and comparable to the effects of longer non-pharmacological treatments. Parent-reported tic severity decreased by 42.99±31.69% from baseline to three months post-treatment. When contrasting the tic-contingent with the tic-non-contingent training versions, we observed a larger improvement in tic-free interval duration in the former case (t(67)=3.15, p=.0025). Additionally, Rush, another measure of tic severity, demonstrated a greater reduction following training with the contingent compared to the non-contingent version (t(47)=3.47, p=.002). Conclusion: The combination of gamified tic triggering with immediate and contingent rewards demonstrates a promising approach for enhancing treatment efficacy in TDs, offering an engaging boost to traditional therapeutic methods.

The authors have declared no competing interest.

NCT06348511

This work was funded by the Young Investigator Award from the Tourette Association of America and the Brainboost Innovation Center at the Sagol School of Neuroscience, Tel Aviv University.

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The study was approved by the ethical committee of the Tel-Aviv Sourasky Medical Center.

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