Over the past three decades, numerous studies have demonstrated a strong and consistent link between child maltreatment and poor health outcomes in adolescence and adulthood. Researchers in multiple fields are now working to understand the causal mechanism between these developmental events, biological changes, and behaviour. One model hypothesizes that the maltreatment–outcomes link may be mediated by changes in neuronal architecture that occurs “as needs and environmental challenges destabilize the existing organizations, necessitating the emergence of new organizations that may prove to be more adaptive than the pre-existing ones in the current context” (Cicchetti and Cohen 2006, p. 22). By the age of 30 months maltreated toddlers tend to show a deficit in the ability to communicate their own affective states (Cicchetti and Beeghly 1987). Maltreated children show a heightened neural response to both positive and negative facial affect (McCrory et al. 2013). Maltreated children are more likely to exhibit impaired emotion regulation patterns while observing a simulated argument between their mothers and a researcher (Maughan and Cicchetti 2002). Women with abuse-related stress show increased activation in brain areas associated with emotional processing and automatic detection of threats (i.e., the amygdala). This emotional processing comes at the expense of reduced activation in brain areas associated with attention, memory, spatial perception, facial recognition, and conscious fear awareness when processing conflicting visual-semantic stimuli (Bremner et al. 2004).

Alterations in brain functioning associated with child maltreatment increase the risk of posttraumatic stress disorder (PTSD) (Banyard et al. 2001; Lansford et al. 2002; Tolin and Foa 2006; Whiffen and Macintosh 2005; Widom 1999). PTSD symptoms reflect the allocation of brain processing away from higher cognitive functions and toward automatic emotion-based systems that are key to scanning for threats (i.e., Ford 2005). This activation of emotion-based systems reflects an overall impairment or inefficiency in self-regulatory processes (e.g., De Bellis and Thomas 2003) and is antithetical to the goal of emotion regulation. Thus, a major potential issue for maltreatment victims is the management of distress and regulation of negative affect (Kim and Cicchetti 2010; Maughan and Cicchetti 2002; Shields and Cicchetti 1998), including shame and anger (Bennett et al. 2005), traumatic stress and depression (Shea et al. 2005), and generalized anxiety (Heim et al. 2000). Those who are able to form secure and positive social connections, self-regulate emotions, inhibit impulses, improve self-control, and delay gratification are more likely to experience better socioeconomic outcomes, be healthier, wealthier, and more successful (Casey et al. 2011; Moffitt et al. 2010; Shoda et al. 1990). Thus, a key construct in supporting resilience in the face of maltreatment is emotion regulation—the use of cognitive or behavioral strategies to influence the occurrence, experience, and expression of emotions (Ochsner and Gross 2005) and the reinterpretation of an event such that it decreases or increases emotion intensity, leading to a reduction of negative affect and the accomplishment of identified goals (Lazarus et al. 1970; Thompson 1994).

Emotion regulation is an important mediator in both the maltreatment-distress and maltreatment-resilience links. Determining which factors bolster emotion regulation and support resilience among maltreated youth as a process of development has received increasing research attention, although examination of resilience-specific interventions lags considerably. Adolescence is a crucial window of opportunity to establish a wellness lifestyle due in part to the heightened health risk behaviours occurring during this life phase (Wekerle et al. 2007), as well as its association with the onset of major adult psychiatric disorders (Kessler et al. 2005). Williams and Nelson-Gardell (2012) highlight the resilience value of such personal characteristics as optimism, positive self-worth, an internal locus of control, social competence, and problem-based, non-avoidant coping styles. This emphasis on improving the “internal environment” amidst an adverse external environment has found support in the mechanism of brain plasticity—the capacity to adapt and fine-tune neural connections—throughout life (Huttenlocher 2002; Li et al. 2006).

Ford (2005) explains that treatment for individuals who present with persistent emotion dysregulation secondary to a history of child maltreatment might be viewed as enabling the person to gain conscious control over her or his neurobiological alarm system. This system, which was altered by extreme stress early in life (McCrory et al. 2011), has become problematic not due to current trauma exposure but rather excess reactivity to subtraumatic stressors in a non-maltreating environment (van der Kolk 2003). Interventions with a mindful component, such as meditation and yoga, may show particular promise in gaining conscious control over the neurobiological alarm system.

With the recent evidence basis for mindfulness meditation in adults (Baer 2003; Hoffman et al. 2010), programs that fall under the general category of “Eastern arts” (i.e., meditation, yoga, tai chi and qigong), particularly accessible in urban environments, may prove useful to bolstering resilience. Here, we summarize the evidentiary base for the relevance of Eastern arts to a maltreated child and youth population in: (1) health issues indicating a need for self-regulation of emotions; (2) emotion regulation as a prime intervention candidate mechanism; (3) the evidence for self-regulation being impacted by Eastern Arts approaches. Studies have shown a beneficial effect of yoga, meditation, and breath work on emotion regulation, relief of PTSD symptoms, modulation of the sympathetic nervous system, improvement in heart rate variability, and clinical symptom reduction (Arch and Craske 2006; Birdee et al. 2009; Brown and Gerbarg 2009; Marmar et al. 1994; Salmon et al. 2009). However, the field is still relatively young, the interventions varied, and the extent of the evidence base among a specifically maltreated or high-risk youth population unknown. As such, the goal of this paper was to evaluate existing evidence regarding the effects of such practices on resilience (i.e., positive health and socioeconomic outcomes) among this vulnerable population. In addition to yoga/meditation/mindfulness, we incorporated a number of “Eastern Arts” in the review, including tai-chi (tiaji), and qi-going (chikung). Tai chi chuan is a martial art originating in China about 300 years ago, which draws on breathing techniques in every motion and pattern (Dunn 1987). Similarly, Qi Gong involves rhythmic breathing coordinated with slow, fluid movement (Posadzki et al. 2009). Thus, despite some variability among Eastern Arts as defined in this review, the common element among all of these systems is the concept of mindfulness meditation and breathing.

In order to evaluate the existing evidence for Eastern Arts on resilience among maltreated youth, we used a scoping review, the purpose of which is to rapidly map the key concepts underpinning a research area, identify the main sources and types of evidence available (Mays et al. 2001), and as a preliminary assessment of the potential size and scope of available research literature. Scoping studies are particularly relevant to young disciplines with emerging evidence in which the paucity of randomized controlled trials makes it difficult for researchers to undertake systematic reviews. Instead, the starting point is to ask questions beyond those related to intervention effectiveness, and possibly generate findings that compliment the results of clinical trials (Levac et al. 2010). These reviews aim to identify the nature and extent of research evidence (Grant and Booth 2009), and as such are particularly useful for mapping the literature and identifying where more in-depth reviews and syntheses can be carried out. Thus, the timeliness and depth of the scoping review results is dependent on the volume of literature that exists in the particular topic area to be scoped (Brien et al. 2010).

The following questions were specifically addressed in our review:

  1. (1)

    What evidence exists in the literature that the Eastern Arts are effective in supporting resilience among child-welfare involved youth? Youth who have been maltreated? At-risk youth?

  2. (2)

    What is the quality of that evidence re: systematic reviews, meta-analysis, randomized controlled trials, experimental designs with control groups, convenience samples, or case studies?

  3. (3)

    What are the findings in terms of significant outcomes? Are there patterns in the positive outcomes that could drive a systematic review of effective interventions to support resilience among child welfare/maltreated youth?

  4. (4)

    What is the quality of the programs that are finding a significant impact? Are they well implemented and well described? Are they expandable and transportable to other regions?

Methods

There are four common reasons for conducting a scoping review: (1) To examine the extent, range and nature of research activity; (2) To determine the value of undertaking a full systematic review; (3) To summarize and disseminate research findings; and (4) To identify research gaps in the existing literature. The framework we used for conducting our scoping review was outlined by Arksey and O’Malley (2005) and previously outlined by Mays et al. (2001). These frameworks stress that the different stages of the review be conducted in a rigorous and transparent way so that others can replicate the process, thereby limiting the concern that scoping studies rarely provide methodological detail about how results were achieved (Davis et al. 2009).

The goal of the current scoping review was to evaluate existing evidence regarding the effects of the eastern Arts (i.e., yoga; transcendental, mindfulness, or compassionate meditation; tai-chi, qigong) on resilience (i.e., positive or improved health outcomes such as substance use, self harm, suicidality, mental health, dating violence, risky sexual practices) among high-risk adolescents receiving Child Protection Services (CPS) and/or who have a history of child maltreatment. The intended outcome of the review was to identify the extent, range, and nature of peer-reviewed research in this area, summarize and disseminate these research findings, and identify gaps in the existing literature for further primary research. The rationale for conducting the review was to examine the potential benefit of Eastern Arts practice for promoting resilience among maltreated/high-risk children and youth.

The stages of conducting a scoping review (Arksey and O’Malley 2005) are: (1) Identify the research question; (2) Identify relevant literature/studies; (3) Study selection; (4) Chart the data; and (5) Collate, summarize and report the results. The Center for Reviews and Dissemination (CRD), which is part of the National Institute for Health Research (United Kingdom) and provides research-based information about the effects of health and social care interventions via databases and systematic reviews, developed the University of York framework. This review framework recommends searching several literature sources, including electronic databases, reference lists of relevant literature, hand-searching key journals, and relevant organizations and conferences (Centre for Reviews and Dissemination 2001). For the present scoping review, we approached the search in multiple steps, first targeting electronic literature databases. We then used predetermined criteria to select relevant articles from all searched references. Finally, the reference list for each of the selected articles was searched for other relevant articles, as well as specific journal issues with related material. Given the suspected dearth of studies in this prescribed area, the search was specifically engineered to return as many even remotely relevant articles as possible, resulting in most studies being eliminated at the study selection phase.

We started by searching the following terms in all possible combinations in the Psycinfo, Medline, PubMed, IndMed, and Social Work Abstract databases:

yoga OR meditat* OR mindful OR transcendent* OR compassion* OR tai chi OR qigong

and

youth OR adolescen* OR young adult OR emerging adult OR secondary student OR high school student

and

child abuse OR child maltreatment OR child welfare OR child protect agency OR trauma OR childhood adverse events OR high risk youth

Systematic review methods develop inclusion and exclusion criteria, based on a specific research question, at the outset of the project to ensure consistency in decision-making. The criteria we used for including a referenced study in the review consisted of the following:

  1. (1)

    The article was an original research study, as opposed to a review

  2. (2)

    The study involved at least some youth between ages 11 and 18

  3. (3)

    The study involved an intervention associated with the targeted Eastern Arts (i.e., yoga; compassionate, mindful, or transcendental meditation; tai chi; qigong)

  4. (4)

    The study involved multiple participants as opposed to an individual case study

  5. (5)

    The methodology and intervention were described well enough to be able to replicate the study

  6. (6)

    The study received institutional ethics review board clearance

We did not include specific involvement with CPS as one of the selection criteria as we wanted to capture youth who had experienced adverse events but had not necessarily been involved with the CPS system. We also wanted to ensure that we included CPS-involved youth who participated in a research study that did not capture their involvement with the CPS system (i.e., they were recruited for the study via other means).

According to the York methodology of scoping reviews (Centre for Reviews and Dissemination 2001), the charting process is multi-staged, involving extraction of information from individual articles. The data that we charted were entered onto a ‘data charting form’ using the Excel database program. The charted variables include the following: Article Title; Author(s); Publication Year; Journal Name; Type of Article (Full Research Report, Brief Research Report, Letter to the Editor, Other); Study Design; Study Design Categorization (Randomized Controlled Trial, Non-Randomized Controlled Trial); Participant Description; Sample Size; Gender Examination; Geographic Location; Intervention Description; Intervention Categorization (Yoga; Meditation [without yoga]; Tai Chi; Qigong; Combination of two or more of the previous); Dependent Variables; Dependent Variable Type (Objective Measure such as blood pressure or heart rate; Self-report Observable Measure such as number of cigarettes smoked; Self-report Subjective Measures such as anxiety level; and combination of two or more of the preceding); Dependent Variable by Category (Physical health; Mental health; Socioeconomic health); Study Quality ScoreFootnote 1 from 0 through 8 (see Table 1); Study Conclusion(s).

Table 1 Study quality rating based on the US Department of Health and Human Services
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We used this table to summarize, collate, and synthesize the uncovered and included literature. Due to the specialized area of inquiry and relative lack of research articles in this area, we contained the final analysis stage to a narrative synthesis where we organized these findings into specific health and social outcome categories that are related to overall resilience. These included: (1) physical health (e.g., body-mass index; cigarette smoking; binge drinking; other drug use; medication use; health care use); (2) mental health (e.g., depression; anxiety; posttraumatic stress); and (3) socioeconomic health (e.g., high school completion; post-secondary education; justice system involvement; employment; stable/safe housing). The literature search was conducted over the course of 3 weeks in the first half of 2013.

Results

We started by conducting a literature search using the databases and all combinations of terms as described in the methods section. This search returned a total of 330 English language peer-reviewed journal articles across all of the examined databases (see Table 2). The articles were read and either included in the review or rejected based on the six-point inclusion criteria, as outlined above. Following this process, eight articles were deemed appropriate for inclusion in the review and are shown in Table 3.

Table 2 Number of articles found under each dependent variable search term in combination with all other search terms (youth OR adolescen* OR young adult OR emerging adult OR secondary student OR high school student AND child abuse OR child maltreatment OR child welfare OR child protect agency OR trauma OR childhood adverse events OR high risk youth)
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Table 3 Resilience programming in scoping review
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Thus, the first result drawn from this scoping review is that the literature examining Eastern Arts as an intervention to promote resilience among maltreated/high-risk youth is extremely limited. Furthermore, the field is widely distributed, as demonstrated by the variation of the eight articles included in the review. These articles examined the impact of 12 1-h weekly yoga sessions on emotional (e.g., self perception) and physical (e.g., flexibility, balance) well-being among inner city children in grades four and five (Berger et al. 2009); transcendental meditation practiced twice a day for 15 min on psychological distress among secondary school students (Elder et al. 2011); mind–body skills on PTSD symptoms among high school students (Gordon et al. 2008); a mindfulness-based program on decreased experiential avoidance and revictimization of sexual assault among female undergraduates who had been sexually abused (Hill et al. 2011); two to three yoga sessions per week (for 11 weeks) on perceived stress and confidence during stress among secondary school students (Khalsa et al. 2012); Cognitively-based compassion training (e.g., teaching; discussion; and meditation practice) for 12 1-h sessions over 6 weeks on salivary C-reactive protein concentration, anxiety, and depression, among foster care youth with early life diversity (Pace et al. 2012); Mind–body skills on depression, hopelessness, and PTSD symptomatology among children and adolescents with PTSD (Staples et al. 2011); and “Peace Power Qigong” meditative movement exercises twice a week for 8 weeks on self esteem, psychological distress and well-being at school among students in the seventh grade (Terjestam et al. 2010).

All of the studies included in the scoping review were full research reports and six of the eight were randomized controlled trials. The other two were pre-post intervention studies. Six of the studies relied mostly on subjective reports of wellbeing/resilience, while one measured objective physiological outcomes (i.e., Salivary C-reactive protein concentration) and one included a self-report observable measure (i.e., meditation practice diary). Those studies that examined only one resilience/outcome category examined mental health outcomes, whereas those that examined several outcomes tended to include mental health and physical health. Socioeconomic health was examined in only two of the selected studies.

In terms of outcomes, it is important to note that all but one of the studies (Hill et al. 2011) showed some improvement in the targeted dependent variable for the Eastern Arts intervention group versus the control group. In some cases the results were more robust, or were seen across most of the dependent variables (e.g., Berger et al. 2009), and in one study, there was a positive correlation between reductions in morning salivary CRP concentrations across the 6-week study period and the number of cognitive-based compassion training practice sessions (Pace et al. 2012). An interesting note relates to the recency of the studies included in this scoping review. The oldest study had been published in 2008 and six of the eight studies had been published in either 2011 or 2012. This speaks to the relatively recent interest in this area of inquiry. Finally, while there has been significant discussion about the quality of studies that have been conducted on yoga and meditation (Toneatto and Nguyen 2007), the average quality rating of the studies included in this review was relatively high, with a mean = 6.25 out of a possible maximum of 8. In this case, the quality of the studies that examine Eastern Arts and resilience among maltreated/high risk youth does not appear to be as poor as some authors have suggested (e.g., Toneatto and Nguyen 2007).

Discussion

The goal of this scoping review was to evaluate existing evidence regarding the effects of Eastern Arts practice as potential resilience programming for maltreated/high-risk adolescents. The intended outcome of the review was to identify the extent, range, and nature of peer-reviewed research in this area, summarize and disseminate these research findings, and identify gaps in the existing literature for further primary research. The rationale for conducting the review was to examine the potential benefit of Eastern Arts practice, as an emotion regulation strategy, for promoting resilience among maltreated/child welfare-involved youth.

The following questions were specifically targeted as part of the review. Here, we provide a discussion that addresses each of these questions by drawing upon the literature examined in the introduction to this review as well as the articles selected for inclusion in the scoping review itself.

  1. (1)

    What evidence exists in the literature that the Eastern Arts are effective in supporting resilience among maltreated/high-risk youth?

In summary, there is very little evidence regarding the effect of Eastern Arts on supporting resilience among maltreated, child welfare-involved, high-risk youth. We were able to locate only eight peer-reviewed English language articles across a number of reference databases.

  1. (2)

    What is the quality of that evidence re: systematic reviews, meta-analysis, randomized controlled trials, experimental designs with control groups, convenience samples, or case studies?

The quality of the studies that do exist is relatively high. All of the studies included in the scoping review utilized a control group in the assessment of their intervention, and six out of the eight used a randomized controlled trial, whereas the other two utilized a pre-post intervention design with controls. We also examined the quality of each of the studies included in the review, using the score system set forth by the US Department of Health and Human Services (HHS) (Scott 2002). The average score (Mean = 6.25 out of a possible high of 8) confirms that the quality of the studies was acceptable, contrary to the suggestion of some researchers who have performed reviews of the literature in this area (e.g., Toneatto and Nguyen 2007).

  1. (3)

    What are the findings in terms of significant outcomes? Are there patterns in the positive outcomes that could drive a systematic review of effective interventions to support resilience among child welfare/maltreated youth?

Seven of the eight studies included in the scoping review indicated at least partial positive outcomes associated with the intervention. The outcomes mostly measured included emotional wellbeing, psychological distress, post-traumatic stress, depression, hopelessness, and self-esteem. Thus, the majority of the studies relied mostly on subjective reports of wellbeing/resilience. While one of the studies examined an objective physiological measure, more studies relying on these types of measures would be helpful, and it would be interesting to see studies that match subjective measures of well-being/psychological distress with objective physiological measures such as heart rate, skin conductance, changes in brain electrical activity, or changes in cerebral blood flow.

The one study that did not show a positive effect implemented a mindfulness-based program to try and reduce rates of sexual assault among female College students (Hill et al. 2011). While the study did not show a statistically significant difference in sexual assaults between the intervention and control groups, it is important to note that the intervention consisted of only two, 2-h group sessions that were spaced approximately 1 week apart, and that the entire study (pre and post measurement) was conducted over the space of approximately 2 months (mean = 9.97 weeks). Thus, the intervention may not have been intensive enough and the there may not have been enough time to robustly measure sexual assault re-victimization (although the authors suggest otherwise). Furthermore, the dependent variable (sexual re-victimization) is a behavioural outcome that is significantly removed from the known impacts and objectives of Eastern Arts practices, and would seem an inappropriate target with a theory of clinical mechanism lacking.

The positive outcomes associated with Eastern Arts interventions in the present review are consistent with a recent qualitative review of mindfulness training among youth aged 16–24. This review concluded that youth were able to improve emotion regulation and gain confidence in their ability to manage life challenges (Monshat et al. 2013). A systematic review of 16 studies found that sitting meditation was an effective intervention in the treatment of physiologic, psychosocial, and behavioral conditions among youth (Black et al. 2009). Trauma-sensitive yoga (TSY) has shown a positive impact on the physical and mental well-being of trauma survivors (Spinazzola et al. 2011). Mindfulness-based stress reduction (MBSR) has been applied to adults with child maltreatment histories, leading to significant reductions in depression (Kimborough et al. 2010). Nedeljkovic et al. (2012) examined the stress reducing effects of 3 months of Taiji practice on psychobiological stress response in 70 healthy men and women. Compared to controls, Taiji participants exhibited a significantly lower stress reactivity of cortisol, and heart rate, as well as lower a-amylase levels. They also reported a lower increase in perceived stressfulness and maintained a higher level of calmness in response to psychosocial stress (Nedeljkovic et al. 2012).

Based on mindfulness meditation and yoga studies published in other areas, the evidence for a relationship between these practices and emotional regulation/dissipation of psychological distress warrants further investigation as it applies to CPS youth and maltreated youth populations. Furthermore, the existing evidence regarding the relationship between emotional regulation and better health outcomes (i.e., resilience) is also sufficient to justify the further examination of these programs among maltreated/high-risk youth.

  1. (4)

    What is the quality of the programs that are finding a significant impact? Are they well implemented and well described? Are they expandable and transportable to other regions?

We found that the articles included in this scoping review described the interventions in enough detail to clearly understand the process, either within the article itself or via referencing a previous article or other source that describes the intervention in detail. With so many different branches of these arts, and a relative lack of systematization among them, an effort to clearly document the intervention will be important in the future.

Conclusions

In conclusion, though the number of articles examining the relationship between Eastern Arts interventions and outcomes among maltreated/high-risk youth is limited at this time, the quality of the studies that have been published, in conjunction with the more extensive evidence outlining a positive impact of yoga and meditation on improving emotional regulation, PTSD, and health outcomes among children, youth, and adults provides support for continuing examination of these interventions. There is sufficient empirical evidence to evaluate such Eastern Arts approaches as potential resilience programming for maltreated youths. These studies were of relatively high quality among the articles included in the current scoping review.

As this field progresses, importantly, the exact interventions used, whether they are traditional yoga, mindfulness meditation, or tai chi motions, must be clearly identified/described and standardized. This will allow for replication and comparison studies, and to develop a solid research evidence and policy base (Burke 2010). Future work may consider critical components to outcomes (e.g., sitting mediation versus moving meditation), as well as how these complement or compare to established exercise-based effectiveness in stress management and emotion regulation. Given the low cost, minimal negative impact, and high accessibility of these approaches in urban centers, and also via technology applications, there is merit in further empirical inquiry into the utility of Eastern Arts-based practices as resilience programming for maltreated, at-risk youth.