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Practice Question construction and Literature Review


The aim of this paper is to provide an evidence-based practice question and literature review, which is a requirement in the Doctor of Nursing Practice (DNP) curriculum. This paper will review the evidence presented in the last five years to discuss and appraise and synthesize studies utilized based on their strength. Lastly, the paper will look at the further research that must be done to increase this discipline with more knowledge.

Introduction and Practices Question

Recently, there has been an increase in attention deficit disorder (ADHD) worldwide. Some of the signs and symptoms of the disorder are difficulties in attention processing and execution of functions. It has been noted that most of the patients diagnosed with ADHD have been developing various challenges of self-regulation indicated by the inability to pay attention and focus (Sibley et al., 2022). There have been limitations of hyperactive activity and failure to control the impulse in these patients. As a result of these defects, there have been identified that the current treatment requires special attention. The short-term and long-term arising from the treatment of ADHD showed there is an academic gap also (Li et al., 2013). The patient is diagnosed with the ailment and has noticed difficulties with daily self-organization skills. Behavioral mechanisms and medication have been at the forefront form of treatment. Some of the research that has been conducted has shown that brain frequency is related to a person's behavior (Bhattacharyya et al., 2021). The various study that has been done indicated that all the children diagnosed with ADHD have abnormal EEG profiles in comparison to children of the same age. In treating the ailment, it was devised that EEG Neurofeedback is appropriate as it can influence the changes in human behavior.


The practice question asks, (P) Are the nurses diagnosing the children with ADHD in the health center and having graduated in the past 1 year (I) Will they be able to differentiate between the medication therapy (C) compared to Neurofeedback (O) in the treatment of the school children at the end of (T) 2 years.

Since many treatment methods have been used in treating the ailment, which follow up different procedures, the literature review will be used to identify whether EEG Neurofeedback is the best alternative in treating the ailment and whether it has negative repercussions. The population being addressed is the health workers and practitioners who have the role and mandate to know the most effective method of treatment. This approach is considered the most appropriate compared to the medication methods due to its long-term effectiveness. The review will look at the different types of treatment and their short-term and long-term impacts on diagnosed individuals. It will later suggest the best alternative to treat ADHD patients.

Literature Review

ADHD is a psychological disorder that disturbs individual attention and causes a lack of hyperactivity. In the United States, ADHD disorder affects approximately 11% of school children. ADHD is grouped into three types; predominantly Inattentive, combined, and Predominantly Hyperactive-Impulsive. Predominantly inattentive is categorized as lack of attention, while combined, it is grouped as lack of both hyperactivity and attention (Shahmoradi, 2019). Hyperactive impulsivity is termed a Squirmy behavior and results from the total failure of attention. Several comorbid behaviors result from ADHD, such as poor social skills, low mood, anxiety, and poor academic performance.

A study conducted by Wang used five different clusters profiles of EEG consisting of 155 boys between 7 to 13 years diagnosed with ADHD (Wang, Horowitz & Tuscano, 2015). This study opted to narrow down the cluster into five. In the first cluster, there was 23% that showed an increase in the Bata activity and had minimal alpha and Theta activities in the frontal regions. It was noted that in the mid-region, there was a minimal Theta as compared to the control areas. In cluster 1, it looked at the children with ADHD, and this category showed an aspect of antisocial and aggressive characteristics. The second category comprises minimal Alpha and beta but increased Theta. In this category of the participant, they were neither fearful nor antisocial. The third cluster was composed of 25% of the sample used had elicited increased Theta and delta activity. The participant in this category indicated insufficient attention. In the 4th cluster, it contributed 25% of the sample and reduced beta activity and increased in Theta. The 5th cluster was composed of the minimum Delta and Theta. In this category, the behaviors were seen as confused. The individuals showed the behaviors of having a few interests, strict routines, and behaviors of arranging the objects (Wang, 2015).

Neurofeedback significantly impacted ADHD patients, and no adverse side effects were identified. This form of treatment is indicated to establish a permanent therapy without any side effects and non-despondence. The information released by the Centre for Disease Control (CDC) revealed that 11% of school children in the United States had been diagnosed with ADHD, a common pediatric disease (Wang, 2015). In treating the ailment, there is an embracement of two categories. This includes the use of behavior therapy and stimulant medication. These two treatments have been embraced to be used in health centers as they have attained the threshold requirement of the evidence-based form of therapy. Despite the treatment being acknowledged by both CDC and (AACAP), there has been a rise in the treatment failing to sustain remedy in many children being diagnosed. This indicates that the therapy fails the mandate of being first prioritized in treating ADHD (Enriquez Geppert et al., 2019).

The studies showed that people’s behavior with ADHD has a high probability of correlating with the subgroups of EEG. The enormous differences between behavioral and neurological aspects make it challenging to identify the treatment that isn't dimensional in effectiveness and capable of giving appropriate results in all DHD subtypes (Friedrich, 2020).

The conduction of Neurofeedback offered a permanent solution to the problem. Neurofeedback is known for operant brain programming frequencies that facilitate the patient being in a position of regulating the brain. It is termed EEG operant conditioning. This method gained popularity after it was identified that humans could control their brain frequencies using operant conditioning (Li, Zhuo & Wang, 2013). Neurofeedback is initiated by placing the electrodes on the scalp to detect the Neuro electric process. The process is normally resolved using computer software that gives auditory feedback involving the frequency of the brain waves. The treatment of children with ADHD using the Neuro-feedback method is based on Beta, Rhythm, Theta, and Sensorimotor (Wang et al., 2015). The Theta and beta is programmed to either increase or decrease based on the client's factors. Neurofeedback has been termed the most effective method of treating ADHD since it is ranked as owing 80% effectiveness and thus plays a central role in minimizing the behavior challenge. On the other hand, the use of stimulant medication is rated as 60% successful (Wang et al., 2015).

Brandeis conducted a study using 100 children aged 6 -13 to determine whether Neurofeedback is effective. In this study, the participants had been diagnosed with ADHD by a well-qualified psychologist. The study showed no variation in Neurofeedback and stimulant medication when the score analysis after the interventions was administered. The conclusion of the study indicated that Neurofeedback has a high-efficiency score (Brandeis, 2012). The studies that Wang conducted identified that the EEG operant program helps to improve the problem present in the behavior of academic performance, intelligence, and attention (Wang et al., 2015). Shahmoradi found that Neurofeedback is significant in children between 8- 12 years who have ADHD. This treatment method helps treat the lack of concentration and reduce impulsive behaviors (Shahmoradi, 2019).

It is beyond a reasonable doubt that stimulant medication has side effects. There is little proof that shows the impacts of the use of stimulant medication. Within 2 to 3 years of the use of drugs, there has been a rise in the dissolution of benefits. Neurofeedback has indicated its effectiveness in the treatment after Pfeiffer performed a follow-up for six months, and the scores of lack of attention, impulsivity, and hyperactivity were appreciated. The two-year study conducted by Shahmoradi (2019) found that the elements that Neurofeedback treated remained constant. The session of Neurofeedback takes an average of 15 minutes and is taken 2 to 3 times a week. The entire training covers 20 to 40 sessions.

In the session, an individual is taught specific arousal feelings and how they trigger different conditions willingly. Neurofeedback offers a long-term impact but also gives the best alternative options on the medication. Though ADHD treatment has been shown to cause blood pressure, anxiety, and depression, Neurofeedback has not indicated any side effects.

Appraisal and Synthesis

The literature on treating ADHD patients has played a splendid role in fixing some gaps in the pre-research. Most medication practices put a lot of focus on the treatment of the ailments but do not pay much attention to the long-term effects, as indicated in the literature review. Initially, the medication practices method was used in treating ADHD patients. Through the research, it was noted that despite being effective, it had long-term side effects. Medication treatment for ADHD resulted in high blood pressure, anxiety, and depression (Shahmoradi, 2019). This was not paid much attention to as there was concentration on the treatment. Since the medication treatment for ADHD, patients had attained the thresholds to be used, it was implemented despite having side effects. This initiated a lot of research and further study regarding the solution to the ailment. The implementation of Neuro-feedback therapy played an essential role in treating the patient with ADHD. It was 80% efficient as compared to medication which had 60 %. In addition, using Neurofeedback didn't have short and long-term impacts on the patients (Machado et al, 2019).

Accordingly, research by Sibley et al. (2022) found that about 30% of children with ADHD at one point or the other tend to experience full remission during the follow-up period; but most of them experience its recurrence after the initial period of remission. Only a few of them (9.1%) demonstrated recovery (sustained remission) by the study endpoint, and only about 10.8% demonstrated stable ADHD persistence across study time points (Sibley et al., 2022).

Based on the literature, it is evident that Neurofeedback significantly impacted ADHD patients, and no adverse side effects were identified. The method offers a permanent treatment without any side effects and any non-despondence. The studies conducted by Wang identified that the EEG operant program helps to improve the problem present in the behavior of academic performance, intelligence, and attention (Scholz et al., 2020).

Another core strength of Neurofeedback is that it can reinforce the other treatment methods. Despite stating Neurofeedback is more effective, it is subject to several weaknesses; first, it is subject to errors that can occur in carrying out the practices. If these errors arise in due case of the therapy, it can lead to many more side effects. This method is, therefore, more sensitive and requires healthcare workers with more skills. Another weakness is that despite this therapy being ranked as 80% effective, it is based on the healthcare worker's skills. This rating is subject to shifting with time as it is not static. No research has also highlighted the appropriate number of sessions required to be more effective. Despite using Neurofeedback, it is worth noting that from the literature review that has been conducted, it is 80% effective, an indication that a lot of research is required to be undertaken so that the level of effectiveness can help sifter to around 95% (Sibley et al., 2022). This will ensure that all the patients that undergo the process are well assured of healing.


In conclusion, while there is an estimate that childhood attention deficit hyperactivity disorder (ADHD) transmits by adulthood in almost 50% of cases; it is however based on single endpoints, and it fails to consider longitudinal patterns of ADHD expression (Sibley et al., 2022).

The Doctor of Nursing practice is based on master's programs that provide an educational base in system leadership, evidence-based practices, and quality enhancement. DNP is a peak practice-based degree that enhances an individual with nursing skills, knowledge, accountability, and comprehensive techniques with the patients. All the nurses who have acquired DNP usually have the highest nursing expertise and therefore work in the clinical and advanced practice setting, administration sets, leadership, and direct patient care. The prominent role of the DNP is enhancing quality improvement, carrying out evidence-based practices, and managing the systems. The DNP uses a science-based concept in comprehending various health features to deliver skills better. Based on the nursing-based methods using Neurofeedback is essential in the treatment of ADHD.

Using Neurofeedback is seen to be more effective when used in the treatment of children living with ADHD as compared to the use of Stimulant medications (Haugg et al, 2020). The use of Neurofeedback has no side effects and it also complements the other forms of treatment as it is well lightened in the literature. Neurofeedback offers a more personal approach than medication. Human error has been present in Neurofeedback and no investigation has been done. This is the core area that requires to be heavily investigated in future studies (Haugg et al., 2020). It has been identified that the main limitation of Neurofeedback is human errors which have acted as a significant hindrance. There is a need for the technicians to address the core concerns of the clients when using it. There is also a need for research to see the number of therapies required to produce the most prudent results of Neurofeedback (Bhattacharyya et al., 2021). The results should also be done to provide visual feedback or Neurofeedback, which would be more effective.


Bhattacharyya, S., Das, S., Das, A., Dey, R., & Dhar, R. (2021a). Neuro-feedback system for real-time BCI decision prediction.  Microsystem Technologies : Sensors, Actuators, Systems Integration, 27(10), 3725-3734. 

Brandeis, D. (2012). The neurophysiology of neurofeedback and neurocognitive training in ADHD.  Neuropsychiatrie De L'Enfance Et De L'Adolescence, 60(5), S83. 

Enriquez Geppert, S., Smit, D., Garcia Pimenta, M., & Arns, M. (2019). Neurofeedback as a treatment intervention in ADHD: Current evidence and practice.  Current Psychiatry Reports, 21(6), 46. 

Freismuth, D., & TaheriNejad, N. (2022). On the treatment and diagnosis of attention deficit hyperactivity disorder with EEG assistance.  Electronics (Basel), 11(4), 606. 

Friedrich, E. V. C. (2020). Designing a Successful Neurofeedback Training for Children with Autism Spectrum Disorder.  Lernen und lernstörungen, 9(3), 175-185. doi:10.1024/2235-0977/a000303

 Retrieved from Publicly Available Content Database 

Li, L., Yang, L., Zhuo, C., & Wang, Y. (2013). A randomized controlled trial of combined EEG feedback and methylphenidate therapy for the treatment of ADHD.

Mazursky-Horowitz, H., Thomas, S. R., Woods, K. E., Chrabaszcz, J. S., Deater-Deckard, K., & Chronis-Tuscano, A. (2017). Maternal executive functioning and scaffolding in families of children with and without parent-reported ADHD.  Journal of Abnormal Child Psychology, 46(3), 463-475. 

Scholz, L., Werle, J., Philipsen, A., Schulze, M., Collonges, J., & Gensichen, J. (2020). Effects and feasibility of psychological interventions to reduce inattention symptoms in adults with ADHD: A systematic review.  Journal of Mental Health (Abingdon, England), ahead-of-print(ahead-of-print), 1-14. 

Shahmoradi, S. (2019b). The effect of neurofeedback on indicators obsessive-compulsive disorder and anxiety.  NeuroQuantology, 17(7), 1-17. 

Sibley, M. H., Arnold, L. E., Swanson, J. M., Hechtman, L. T., Kennedy, T. M., Owens, E., Molina, B. S. G., Jensen, P. S., Hinshaw, S. P., Roy, A., Chronis-Tuscano, A., Newcorn, J. H., & Rohde (2022). Variable patterns of remission from ADHD in the multimodal treatment study of ADHD.  The American Journal of Psychiatry, 179(2), 142-151. 

S. V. Machado, F., Casagrande, W. D., Frizera, A., & da Rocha, Flavia E. M. (Oct 2019). Development of serious games for neurorehabilitation of children with attention-deficit/hyperactivity disorder through neurofeedback. Paper presented at the 91-97.   

Wang, C. H., Mazursky-Horowitz, H., & Chronis-Tuscano, A. (2015). Is parental ADHD related to child ADHD treatment response?  The ADHD Report, 23(3), 1-5,10.