Responsive Therapeutic Environments: A Dual-Track Review of the Research Literature and Design Case Studies in Art Therapy for Children with Autism Spectrum Disorder

Abstract

Art therapy serves as a crucial intervention modality for children with autism spectrum disorder (ASD), demonstrating unique value in emotional expression, sensory integration, and social communication. However, current practice presents critical challenges, including the disconnect between design expertise and clinical needs, unclear mechanisms of environmental factors’ impact on therapeutic outcomes, and insufficient evidence-based support for technology integration. Purpose: This study aimed to construct an evidence-based theoretical framework for art therapy environment design for children with autism, clarifying the relationship between environmental design elements and therapeutic effectiveness. Methodology: Based on the Web of Science database, this study employed a dual-track approach comprising bibliometric analysis and micro-qualitative content analysis to systematically examine the knowledge structure and developmental trends. Research hotspots were identified through keyword co-occurrence network analysis using CiteSpace, while 24 representative design cases were analyzed to gain insights into design concepts, emerging technologies, and implementation principles. Key Findings: Through keyword network visualization analysis, this study identified ten primary research clusters that were systematically categorized into four core design elements: sensory feedback design, behavioral guidance design, emotional resonance design, and therapeutic support design. A responsive therapeutic environment conceptual framework was proposed, encompassing four interconnected components based on the ABC model from positive psychology: emotional, sensory, environmental, and behavioral dimensions. Evidence-based design principles were established emphasizing child-centeredness, the promotion of multisensory expression, the achievement of dynamic feedback, and appropriate technology integration. Research Contribution: This research establishes theoretical connections between environmental design elements and art therapy effectiveness, providing a systematic design guidance framework for interdisciplinary teams, including environmental designers, clinical practitioners, technology developers, and healthcare administrators. The framework positions technology as a therapeutic mediator rather than a driver, ensuring technological integration supports rather than interferes with children’s natural creative impulses. This contributes to creating more effective environmental spaces for art therapy activities for children with autism while aligning with SDG3 goals for promoting mental health and reducing inequalities in therapeutic access.

1. Introduction

Autism spectrum disorder (ASD) represents a complex neurodevelopmental condition characterized by persistent deficits in social communication and interaction, alongside restricted and repetitive patterns of behavior, interests, or activities [1]. Additionally, individuals with ASD frequently exhibit atypical sensory processing patterns that can significantly impact their daily functioning and social engagement [2]. These core symptoms often result in substantial challenges for children with ASD in establishing meaningful interpersonal relationships and expressing emotions effectively within conventional therapeutic frameworks [3].

As a primarily non-verbal, creative intervention approach, art therapy provides an alternative communicative medium that can circumvent the social and linguistic barriers typically encountered by this population, thereby facilitating improvements in behavioral regulation, emotional expression, and social interaction capabilities [4,5]. Art therapy has emerged as a particularly promising therapeutic modality for children with ASD [6]. The efficacy of art therapy interventions for children with autism spectrum disorder extends beyond therapeutic methodologies alone, with emerging evidence highlighting the critical role of environmental design in treatment outcomes [7].

Art therapy environment design for children with ASD faces significant challenges, categorized into user-centered barriers and designer limitations.

User-centered barriers primarily stem from the inherent characteristics of ASD. Children with ASD frequently exhibit medical anxiety toward unfamiliar therapeutic environments, personnel, or procedures, resulting in avoidance behaviors that undermine treatment participation [8,9]. Concurrently, their fundamental social communication deficits manifest as emotional detachment during therapeutic sessions, impeding the establishment of meaningful therapeutic relationships [10,11]. The multisensory nature of art therapy interventions poses additional complications, as the convergence of visual, auditory, and tactile stimuli may trigger sensory overload, precipitating emotional dysregulation or behavioral disruptions [12]. These challenges are further exacerbated by the characteristic resistance to environmental changes and prevalent self-esteem issues among children with ASD, which collectively intensify barriers to therapeutic engagement [13]. For designer limitations, integrating an in-depth understanding of art therapy professional knowledge to meet core medical needs while focusing on interactive experience and aesthetic creativity presents a significant challenge in the design process [14,15]. Furthermore, emerging technologies such as virtual reality (VR) systems and wearable devices present substantial learning costs and challenging patient compliance issues during implementation [16,17]. Design approaches that emphasize immediate sensory feedback and engagement enhancement may overlook the genuine needs of children with autism regarding long-term developmental objectives, including independent living skills, communication abilities, and emotional regulation [18]. These challenges underscore the inherent limitations of the current art therapy environment design for children with autism.

Within the research domain, although considerable literature has accumulated in the field of autism therapy for children, existing studies predominantly focus on traditional disciplines such as psychology, medicine, and education [19]. However, there remains a significant gap in specialized research regarding environmental design as a critical component tailored for art therapy [20]. Current research primarily concentrates on broader aspects of art therapy, including therapeutic approaches, intervention strategies, and efficacy assessments, such as the effects of artistic activities on social skills and emotional expression in children with autism, or the therapeutic applications of different artistic media [21,22]. These studies typically treat environmental factors as background variables or secondary considerations, lacking systematic analysis and theoretical framework development from a design discipline perspective for these specialized therapeutic environments [23]. Furthermore, many fail to effectively consider the integration of art therapy activities within therapeutic environments [24,25,26]. Research is particularly scarce in specific environmental design dimensions that combine with art therapy approaches, including spatial design, sensory environment modulation, and human-computer interface design [27,28].

This research gap not only limits our understanding of how environmental factors influence therapeutic outcomes but also impedes the development of evidence-based professional therapeutic environments for autism art therapy. Therefore, there is an urgent need to systematically explore the design principles and key technologies of art therapy environments for children with autism from the unique perspective of design disciplines, thereby addressing this important interdisciplinary research gap.

The rapid advancement of digital technologies in therapeutic environments presents both unprecedented opportunities and significant challenges for autism art therapy practice. While emerging technologies such as virtual reality, biometric sensing, and interactive projection systems demonstrate promising potential in supporting children with ASD, a critical gap exists in understanding how to appropriately integrate these technologies without overwhelming the therapeutic art-making process or compromising the fundamental human connections essential to effective therapy. This research addresses the core question: how can environmental design guide the optimal application of technology in art therapy spaces for children with autism, ensuring that technological elements serve as therapeutic mediators rather than disruptive drivers? This research aims to establish a theoretical framework for autism-centered art therapy environment design and provide practical guidance for developing evidence-based therapeutic spaces, thus focusing on several sub-research questions.

• Q1: Requirement identification. What are the specific environmental needs of children with autism during art therapy activities?
• Q2: Element identification. Which spatial design elements effectively support the art therapy process for children with autism?
• Q3: Implementation path. How can design methods and digital technologies be effectively integrated to realize these supportive spatial elements?
• Q4: Principle construction. How to formulate design guidance of therapeutic built environments for children with autism?
• Q5: Mental health. How can built environments contribute to the mental well-being of children with autism and their caregivers, in line with the targets outlined in Sustainable Development Goal (SDG) 3.4?
• Q6: Inclusiveness. In what ways can inclusive and affordable design approaches improve universal access to therapeutic environments for children with autism, as stipulated by SDG 3.8?
• Q7: General goal. How can this research align with the broader goals of SDG 3, ensuring a holistic approach to promoting well-being and reducing inequalities in therapeutic spaces for children with autism?

To systematically investigate this question, we employ a dual-track methodology that combines bibliometric analysis of research literature with empirical analysis of built environment case studies. This paper is organized as follows: Section 2 presents the dual-track research methodology, detailing the literature selection criteria for Web of Science database searches and case study selection protocols for design implementation projects. Section 3 reports the results of bibliometric analysis, including keyword network visualization, temporal evolution patterns, and citation burst analysis. It also establishes the responsive therapeutic environment framework. By integrating findings from both literature and case analysis, it proposes four core design elements and their corresponding implementation principles. Section 4 discusses the theoretical contributions, practical implications, and limitations of the study, then concludes with evidence-based design recommendations and future research directions. This methodological convergence enables us to bridge the gap between academic research insights and professional design practice, ultimately producing a comprehensive technology implementation framework for responsive therapeutic environments that serves as both a theoretical foundation and practical guidance for interdisciplinary teams working in autism art therapy environment design.

2. Materials and Methods

This study adopts a dual-track approach comprising bibliometric analysis and micro-qualitative content analysis to construct a comprehensive data foundation (see Figure 1). The first track focuses on establishing a literature-based data foundation, while the second track develops a case-based data foundation.

Design constitutes an independent discipline with its own intellectual and practical culture [29]. So this dual-track approach enables calibration of theoretical insights with empirical evidence for designers, enhancing the robustness and validity of research findings. A literature review serves to establish a robust academic foundation by presenting a clear theoretical framework. Conducting case analysis within this framework can prove highly beneficial and effective for designers [30]. Because precedent-based research has proven particularly effective in architectural and design education. Studies demonstrate that structured extraction of embedded knowledge through precedent analysis in studio teaching contexts represents one of the most effective pedagogical approaches, serving as a valuable resource for shaping design understanding and practice [31,32]. Case analysis aims to extract the embedded knowledge from exemplary projects, which have achieved practical success and gained professional recognition. By doing so, it was possible to cover both the wide range of existing academic research and the in-depth practical implementation.

2.1. Literature Track: Selection Criteria and Data Foundation Construction

The literature track employed systematic database searches in WOS Core Collection to build the theoretical foundation of this study.

Utilizing the keywords “autism” and “art therapy”, 687 records were initially retrieved. The screening process (see Figure 2) began with keyword screening. During this stage, 506 records were excluded for not being related to the keyword “Design”, and 5 records were excluded for not being within the period of 2015–2025. After that, titles and abstracts of the remaining 176 records were screened, and 89 records were excluded for not matching the inclusion criteria. After systematic screening, 87 high-quality studies were retained to form the core literature data foundation, spanning theoretical frameworks, empirical findings, and methodological approaches relevant to the research domain.

2.2. Case Track: Selection Criteria and Data Foundation Construction

The other section was designed to construct an empirical data foundation through systematic identification and analysis of representative cases that provide real-world insights into the research phenomenon (see Figure 3).

Cases were systematically sourced from different channels to ensure comprehensive coverage of design types and regional variations: design award collections, such as Reddot awards and Interior Design’s annual Best of Year Awards. The multi-source approach enables the construction of a diverse and robust case-based data foundation.

After rigorous screening, 24 projects were chosen to establish the core data foundation, reflecting varied situations. This case-based data foundation guarantees geographical diversity, temporal variation, and contextual depth.

To examine how the proposed theoretical frameworks are applied in practice, this study establishes a multi-level case study approach, informed by the preceding theoretical analysis and literature review.

To ensure the comprehensiveness and relevance of the case database, we adopted the following inclusion criteria:

• cases must be centered on therapeutic environments specifically designed for children;
• incorporation of sensory design components or elements of art therapy;
• publication between 2012 and 2024 in peer-reviewed journals, reputable design award repositories, or official project websites;
• publicly accessible information, or verifiability through site investigation or institutional communication.

While some cases, particularly those from design awards such as the Red Dot Award, were conceptual in nature, we included them only if they demonstrated feasible, user-centered design principles grounded in plausible therapeutic contexts.

2.3. Bibliometric Analysis

This phase utilized the CiteSpace 6.3.1 software tool and was conducted through three sequential steps. First, the keyword network relationships within the obtained clusters were examined. The second step involved a timeline analysis of keywords across different clusters. The third step focused on analyzing keyword burst patterns to identify research hotspots and trends from a more detailed perspective. Through this approach, an objective and comprehensive understanding of the current development landscape and the embedded research hotspots and trends can be achieved.

2.4. Micro-Qualitative Content Analysis

Based on the research hotspots and trends identified through quantitative analysis in the previous step, the essential elements that environmental spaces designed for art therapy for children with autism should possess were summarized from a designer’s perspective, constructing a conceptual framework among these elements. Following this framework, a detailed case analysis was conducted to enrich the conceptual framework with design practice experience, ultimately summarizing the usability techniques and design principles for each design element.

3. Results

3.1. Bibliometric Analysis

3.1.1. Keyword Network Visualization

Through keyword co-occurrence analysis conducted with CiteSpace software, nine clustering outcomes were derived (see Figure 4). Based on the cluster analysis results, the research domain demonstrates a well-structured thematic organization comprising nine distinct clusters that collectively represent the evolutionary spectrum from traditional therapeutic approaches to cutting-edge digital innovations (see

Table 1. Cluster analysis results and LSI labels (generated by the authors).

No	ClusterID	Size	Silhouette	Mean (Year)	Label (LSI)
0	Clinical application	33	0.71	2020	art therapy; clinical applications; mental disorders; medical interventions; neuromodulation interference technology
1	Robotics	30	0.97	2015	assistive robots; conversational agent; human-computer interaction; neurodevelopmental disorder; long-term interaction
2	Creative art	26	0.749	2021	creative arts; social stories; professionals perspectives; immersive experiences; creative arts therapies
3	Facial emotion	25	0.879	2021	facial emotion; reliability; recognition; individuals; children
4	Cross-model treatment	21	0.966	2017	action research; full body experience; music medicine; cross-modal task
5	Music and movement	21	0.89	2019	dance movement therapy; couple therapy; dance movement psychotherapy; multiple case study research
6	Social skills	19	0.976	2020	social skills; music therapy; motor skills; mirror system; autism spectrum disorder
7	Physiological Interaction	17	0.958	2018	physiological signals; mixed methods research; evidence-based practice; music therapy
8	Digital therapy	13	0.946	2022	affective computing; autism; machine learning; computer vision; deep learning; emotion recognition
9	Career Development	11	0.963	2025	young adults; career development; content validation; employment; work; pre-labor

).

Cluster 0 (clinical application), representing primary applications, emerges as the largest research cluster with 33 publications and a mean publication year of 2020, exhibiting good clustering quality (silhouette = 0.71). This cluster predominantly focuses on the practical implementation of art therapy within clinical settings, encompassing critical areas such as mental disorder treatment, medical interventions, and neuromodulation interference technology. Notably, the cluster emphasizes comprehensive interventions and adjuvant therapy applications specifically designed for autistic children, reflecting the trend toward specialized and personalized clinical practice development.

As for technology-driven aspects, Cluster 1 (robotics) comprises 30 publications representing relatively early research endeavors (mean year = 2015) while maintaining exceptional clustering quality (silhouette = 0.97). This cluster investigates the application of assistive robots, conversational agents, and human–computer interaction in treating neurodevelopmental disorders, with particular emphasis on long-term interaction paradigms. The research scope extends to biomedical mechanisms, including matrix metalloproteases and neuroinflammation studies. Cluster 8 (digital therapy), despite its smaller size (13 publications), represents the most cutting-edge technological developments (mean year = 2022) with high clustering quality (silhouette = 0.946). This cluster integrates advanced technologies including affective computing, machine learning, computer vision, and deep learning to develop mobile health applications, emotion recognition tools, and diagnostic systems, signifying the digital transformation of therapeutic methodologies.

Cluster 2 (creative art) and Cluster 5 (music and movement) constitute two significant branches of arts-based interventions, containing 26 and 21 publications, respectively. The former concentrates on creative arts therapies, social stories, and immersive experiences (mean year = 2021), while the latter specializes in dance movement therapy and multiple case study research in music therapy (mean year = 2019). Both clusters demonstrate substantial clustering quality (0.749 and 0.89, respectively).

Cluster 3 (facial emotion), Cluster 6 (social skills), and Cluster 7 (physiological interaction) form the core domains of skill-based training interventions. Cluster 3 focuses on facial emotion recognition reliability studies (mean year = 2021, 25 publications), Cluster 6 explores the integration of social skills development with music therapy approaches (mean year = 2020, 19 publications), and Cluster 7 investigates the relationship between physiological signals and human interaction dynamics (mean year = 2018, 17 publications). All three clusters exhibit exceptionally high clustering quality (0.879–0.976), indicating highly specialized research themes with strong internal coherence.

Cluster 4 (cross-modal treatment) explores action research, full-body experiences, and cross-modal tasks in music medicine (mean year = 2017, 21 publications), representing an integrative approach to therapeutic methodologies. Cluster 9 (career development), while the smallest in size (11 publications), addresses the most contemporary concerns (mean year = 2025) by focusing on young adults’ career readiness and life planning, demonstrating the field’s expansion toward life skills cultivation.

These identified clusters collectively illustrate the research domain’s evolutionary trajectory from early robotic assistance applications (2015) to contemporary digital therapeutics and career development initiatives (2022–2025). This progression reveals four primary research trajectories: technological innovation, clinical application, arts-based therapy, and skills development. The consistently high clustering quality across all clusters (ranging from 0.71 to 0.976) indicates well-defined thematic differentiation with strong internal consistency, suggesting a mature and methodologically robust research landscape that effectively bridges traditional therapeutic approaches with emerging technological paradigms.

3.1.2. Research Hotspot Temporal Evolution

The timeline view (see Figure 5) demonstrates a clear temporal evolution of art therapy design research for autistic children, revealing three distinct developmental phases.

During the early focus period (2010–2015), researchers established fundamental diagnostic criteria and intervention frameworks, with particular emphasis on neurobiological underpinnings and behavioral manifestations of autism spectrum conditions, while facial emotion recognition studies and music therapy approaches laid the groundwork for subsequent artistic interventions.

The intermediate development phase (2015–2020) witnessed a paradigmatic shift toward the integration of creative arts with autism communication strategies, marking a critical turning point in therapeutic intervention design. This period was characterized by the emergence of creative arts interventions as a distinct research domain, accompanied by the development of comprehensive programs that simultaneously addressed multiple developmental domains through mixed-methods and physiological evaluation frameworks.

The contemporary phase (2020–2025) represents a technological and humanistic renaissance, characterized by the convergence of art therapy with neuromodulation techniques and the integration of artificial intelligence applications that enable personalized treatment protocols. The incorporation of neuroinflammation research, assistive robotics technology, and smartphone-based applications has democratized access to therapeutic resources while expanding the research focus from childhood-specific interventions to comprehensive lifespan considerations, thereby establishing a technology-enhanced, integrated care framework for autism spectrum disorders.

This chronological analysis offers a comprehensive framework for understanding how art-based interventions have evolved from supplementary approaches to core evidence-based practices within the autism research landscape.

The visualization reveals that creative arts interventions (Cluster 2) represent a significant and evolving research domain within autism spectrum disorder studies, demonstrating substantial growth trajectory from 2015 onwards. This temporal progression indicates that art therapeutic activities have transitioned from peripheral interventions to mainstream evidence-based practices in autism care. The network analysis shows strong interconnections between creative arts and core autism research nodes, suggesting that artistic interventions are increasingly recognized as fundamental components of comprehensive autism support strategies rather than supplementary approaches.

The emergence of therapeutic art activities as a distinct research cluster reflects the field’s growing understanding of autism’s diverse cognitive and sensory profiles. Children with autism often demonstrate unique strengths in visual processing, pattern recognition, and creative expression, which can be effectively leveraged through carefully designed artistic interventions. The bibliometric data suggest that researchers have increasingly recognized art therapy’s potential to address multiple domains simultaneously, including social communication, emotional regulation, sensory integration, and self-expression, making it particularly well-suited for the multifaceted needs of autistic children.

Design research in art therapeutic activities for autistic children requires a systematic understanding of both autism-specific considerations and evidence-based art therapy principles. The visual analysis indicates that contemporary approaches increasingly integrate cross-modal treatment strategies (Cluster 4) with creative arts interventions, suggesting that effective design must consider multisensory engagement and individualized adaptation. This convergence implies that art therapeutic activity design should incorporate diverse modalities (visual, tactile, auditory, and kinesthetic) to accommodate the varied sensory preferences and processing differences characteristic of autism spectrum conditions.

The network visualization demonstrates significant connections between creative arts and digital therapy (Cluster 8), indicating that modern art therapeutic design increasingly incorporates technological elements. This technological integration offers unprecedented opportunities for personalization, real-time feedback, and objective progress monitoring in art therapy sessions. Digital platforms can provide structured frameworks while maintaining the creative freedom essential to artistic expression, potentially addressing the dual needs of autistic children for both predictability and creative outlet. The design of such interventions must carefully balance technological enhancements and the need to preserve fundamental therapeutic relationships and tactile engagement that remain central to effective art therapy.

Future directions in art therapeutic activity design for autistic children should embrace the interdisciplinary convergence, particularly the integration with social skills development (Cluster 6) and physiological interaction research (Cluster 7). This suggests that effective art therapy design must consider not only creative outcomes but also measurable improvements in social engagement, stress reduction, and overall well-being. The evolution toward evidence-based practice demands that art therapeutic activities be designed with clear objectives, systematic implementation protocols, and robust outcome measurement strategies that can demonstrate therapeutic efficacy while preserving the inherent creativity and joy that make art therapy uniquely powerful for autistic children.

3.1.3. Keyword Burst Analysis

In addition to cluster-level patterns, citation burst analysis offers a dynamic view of emergent concepts and shifting research priorities. The citation burst analysis (see Figure 6) of autism-related art therapy design research reveals a systematic evolution of research priorities across three distinct temporal phases, characterized by progressively sophisticated theoretical frameworks and technological integration.

The initial phase (2015–2020) demonstrated a foundational research focus on primary populations, with “individuals” (strength: 1.52) and “infants” (strength: 0.8) emerging as dominant research subjects, reflecting the field’s early emphasis on establishing baseline understanding of autism spectrum presentations across developmental stages.

The intermediate cognitive-psychological phase (2019–2021) witnessed a significant theoretical deepening, marked by the simultaneous emergence of multiple interconnected concepts including “mental health” (strength: 1.15), “cross-modal task” (strength: 0.77), “bodily self-consciousness” (strength: 0.77), and “deep pressure” (strength: 0.77). This convergence indicates a paradigmatic shift toward understanding the multisensory and embodied aspects of autism, particularly emphasizing the therapeutic potential of tactile and proprioceptive interventions within art therapy frameworks.

The contemporary technological integration phase (2022–2023) represents a revolutionary convergence of art therapy with digital innovation, characterized by an unprecedented cluster of technology-enhanced intervention keywords. The simultaneous emergence of “computer vision” (strength: 1.19), “art therapy” (strength: 0.99), “affective computing” (strength: 0.79), “digital therapy” (strength: 0.79), “emotion recognition” (strength: 0.79), and “design” (strength: 0.79) demonstrates the field’s transition toward sophisticated, technology-mediated therapeutic approaches that maintain the core humanistic values of arts-based interventions while leveraging computational advances for personalized treatment delivery.

This emergent pattern is highly encouraging, indicating that the field is undergoing a significant transition from fundamental research toward technology-enabled practical design applications. The integration of art therapy with digital technologies and affective computing presents novel intervention opportunities for children with autism spectrum disorders, representing a promising avenue for future research endeavors.

3.2. Design Framework of Responsive Therapeutic Environments

The effectiveness of art therapy is often influenced by the therapeutic environment [33]. How to integrate the advantages of modern digital technology with art therapy to create a setting that supports emotional expression and social interaction has become a key challenge in current design practice [23,27]. This paper defines a responsive therapeutic environment as a therapeutic space that utilizes advanced technologies and design methods to sense and respond in real time to the emotional, behavioral, and physiological changes of patients. Specifically for children with ASD, such an environment employs intelligent sensing systems, interactive art installations, and multi-sensory stimulation to support children in achieving therapeutic outcomes through artistic creation, emotional expression, and social interaction [34].

Based on the comprehensive bibliometric analysis and keyword co-occurrence network visualization, four core design elements for responsive therapeutic environments were systematically derived from the ten identified research clusters (see Figure 7). Therapeutic support design emerged from integrating Clusters 0 (clinical applications), 8 (digital therapy), and 9 (career development), which collectively emphasize evidence-based clinical interventions, technology-enhanced therapeutic tools, and long-term developmental outcomes. Behavioral guidance design synthesized insights from Clusters 1 (robotics), 2 (creative arts), and 4 (cross-modal treatment), focusing on interactive technologies, artistic interventions, and multimodal approaches that facilitate behavioral regulation and engagement. Emotional resonance design consolidated findings from Clusters 3 (facial emotion), 5 (music and movement), and 6 (social skills), addressing emotional recognition, expressive therapies, and social communication enhancement. Finally, sensory feedback design directly corresponded to Cluster 7 (physiological interaction), emphasizing real-time environmental responsiveness based on physiological signals and sensory processing needs. This systematic clustering-to-element transformation ensures that each design category is grounded in substantial empirical evidence while maintaining clear theoretical distinctions for practical implementation.

For children with ASD undergoing art therapy activities, designing a responsive therapeutic environment is crucial, as these children face unique challenges in emotional expression, social interaction, and behavioral management [35,36].

Contemporary frameworks in therapeutic environment design demonstrate substantial emphasis on sensory qualities. Notably, the three-factor therapeutic framework establishes quantifiable thresholds for sensory quality, intelligibility, and predictability through rigorous neurobehavioral validation studies [26]. Traditional environmental design frameworks for autism provide seven fixed design criteria (acoustics, spatial sequencing, escape spaces, compartmentalization, transitions, sensory zoning, and safety), while our framework introduces dynamic responsiveness and real-time adaptation capabilities [37]. However, these established approaches lack sufficient consideration for dynamic intervention and interaction. Evidence-Based Design frameworks adopt an eight-step process mainly centered on post-occupancy evaluation and iterative improvement, which has great implications for the design of healing built environments [38]. However, in general medical environments, these frameworks do not comprehensively cover the characteristics of the integration of art therapy activities, art experiences, and medical procedures. While biophilic design theory provides valuable insights for healing built environments through strategies such as spatial configuration patterns, multi-sensory engagement protocols, organic material selection criteria, and daylighting strategies optimization [39], its primary emphasis remains on analog natural elements. This theoretical framework demonstrates limited incorporation of emerging digital technologies, including intelligent environmental modulation systems, interactive therapeutic interfaces, and data-driven optimization tools that are increasingly critical in modern therapeutic environment design.

While these traditional therapeutic environments often lack flexibility and personalization, they fail to respond promptly to children’s emotional and behavioral changes during activities [9,20,24,28,40,41]. For the design of art therapy environments for children with autism, it is of the utmost importance to focus on the behavioral therapy and emotions of these children. This emphasis not only addresses the shortcomings of traditional settings but also forms the cornerstone for the development of the proposed framework, enabling it to be more responsive, individualized, and ultimately more effective in meeting the unique needs of autistic children during the art therapy process.

Grounded in the ABC (activating events (A), beliefs (B), and consequences (C)) model from rational emotive behavior therapy (REBT) [42], we propose a conceptual framework for responsive therapeutic environment design (see Figure 8). As a cognitive–behavioral paradigm, the ABC model establishes a causal chain where activating events (A) trigger beliefs (B) that subsequently drive emotional and behavioral consequences (C) [43]. The framework (see Figure 8) integrates four core components: the environment, sense, emotion, and behavior.

The environment, representing the carrier of four design elements, is a holistic entity created by the integration of sensory, emotional, therapeutic, and behavioral aspects.

Sense serves as the interface between the environment and humans, tasked with capturing and processing environmental information. In ASD therapeutic environments, to address the imbalance between sensory overload and sensory-seeking behaviors [12], sensory feedback design primarily acts on this component, contributing to the transition from activating events to positive beliefs.

Emotion, in the ABC model, has belief as the key driving force, directly influencing children’s perception of and reactions to the environment [43]. Emotional resonance design creates an empathetic connection, allowing ASD children to feel understood and comforted. Therapeutic support design offers targeted interventions to alleviate negative emotions and promote positive emotional states. Together, they work towards improving the emotional well-being of children within the environment.

Behavior, as another consequence, is further strengthened by both therapeutic support design and behavioral guidance design. Therapeutic support design helps to modify behavior by addressing underlying emotional or psychological barriers. Behavioral guidance design, meanwhile, provides clear instructions, incentives, and structured activities that encourage positive and desired behaviors. Their combined effect not only shapes the behavioral outcomes but also influences the overall cycle among the environment, sense, emotion, and behavior components.

This framework clarifies ambiguities in component relationships by establishing systematic correspondences between design and positive psychology mechanisms.

The proposed responsive therapeutic environment framework represents a significant theoretical advancement over existing approaches in several key areas.

Compared to the traditional framework [37], our framework enables environments to actively respond to children’s changing emotional and behavioral states during art therapy sessions. Unlike traditional evidence-based design frameworks [38], our framework integrates real-time environmental responsiveness as a core design principle rather than a post-implementation assessment tool. Extending beyond biophilic design theory and attention restoration theory, our framework engages advanced sensing technologies and affective computing to create personalized therapeutic experiences that adapt to individual children’s unique autism spectrum presentations.

The framework operates as a dynamic, cyclical system where emotion drives the child’s receptivity to therapeutic interventions and environmental stimuli. Sense encompasses the multisensory processing mechanisms that translate environmental inputs into meaningful experiences, directly corresponding to our identified sensory feedback design elements [1,23,24,28,44]. The healing environment represents the comprehensive therapeutic space that integrates all design considerations, aligning with therapeutic support design principles [18,25,26,45]. Finally, behavior reflects the observable therapeutic outcomes and adaptive responses, supported by behavioral guidance design strategies [11,17,46,47,48,49].

Critically, emotional resonance design permeates all components of this framework, serving as the connecting mechanism that enables dynamic interactions between emotion, sensory processing, environmental features, and behavioral outcomes [12,43,50,51]. This creates a responsive feedback loop where each component continuously informs and adapts to the others, enabling truly personalized therapeutic experiences. The core of this design concept lies in dynamic interaction, which stimulates emotional resonance and behavioral guidance in children, thereby enhancing psychological, emotional, and social abilities [48,52].

3.3. Micro-Qualitative Content Analysis

3.3.1. Multi-Level Case Study

The final database comprised 24 cases from nine countries, covering a range of cultural contexts (e.g., China, the United States, and Japan) and typologies, including hospitals, public spaces, and mobile facilities. This diversity enabled cross-sectional analysis of design strategies in art-based therapeutic interventions across institutional, cultural, and technological domains (see Figure 3).

Preliminary observations revealed a number of patterns across the categorized cases. Projects under sensory feedback design were predominantly small-scale interventions, with a strong presence of product-oriented solutions. In contrast, cases categorized under behavioral guidance design and emotional resonance design more frequently addressed spatial design dimensions, including therapeutic room layouts and environmental cues. Meanwhile, therapeutic support design was often associated with embodied intelligence systems and hybrid digital–physical platforms, emphasizing integration across online and offline settings.

In addition to global cases, this database also includes children’s art therapy projects developed by our research team. Together, these projects form a technically diverse and thematically focused repository centered around key themes such as “children’s art therapy,” “autism-friendly healing environments,” and “sensory-integrated spatial design.”

To evaluate the selected cases, we adopted a three-part analytical structure, sensory modalities addressed, underlying interactive technologies and reported or intended therapeutic functions. This enabled a systematic comparison across projects, beyond descriptive narration.

Sensory Feedback Design

Sensory feedback designs utilize real-time multisensory stimuli, such as color shifts, sound effects, and tactile responses, to react to children’s emotional and behavioral cues. Through dynamic sensory input, these carriers stimulate emotional resonance, encourage engagement, and enhance interactive experiences. Sensory feedback design directly influences children’s immediate perception and beliefs about their environment. By integrating environmental sensing technologies, responsive therapeutic environments can enhance emotional connection, relaxation, and sensory regulation for children with autism. These strategies are particularly beneficial for children with high sensory sensitivity, helping them receive emotional support through elements such as temperature, humidity, lighting, and shadow. The structural case descriptions are presented in Table 2.

• Biophilic Regulation Systems: Using sensors and intelligent control systems, the environment can dynamically adjust parameters such as temperature, humidity, and scent in response to a child’s behavioral and emotional states. For example, at the Shanghai Children’s Medical Centre, an indoor light-and-shadow system presents seasonal scenes based on changes in climate or children’s emotional cues, creating a soothing and immersive atmosphere [45].
• Acoustic Modulation Technologies: Sound sensors and automated audio systems allow the space to respond in real time to children’s emotional needs. Music listening has been systematically demonstrated to alleviate anxiety and promote emotional expression in children and adolescents [53]. Moreover, cross-modal therapeutic strategies, such as integrating rhythm-based music therapy with visual interaction, have shown promising potential in enhancing social engagement and trauma recovery among neurodiverse youth [54]. Starrypia is an augmented reality (AR)-based music-assisted art therapy application designed to support children with mild ASD. By integrating principles of applied behavior analysis with sensory integration training, the application delivers multisensory interventions aimed at enhancing users’ attention span and emotional regulation. Through interactive AR experiences and music engagement, Starrypia offers a playful yet therapeutic environment that facilitates cognitive and emotional development in children with mild ASD [55].

Table 2. Evaluation Framework of Sensory Feedback Design (generated by the authors).

Project	Source	Sensory	Description	Therapeutic Role	Validation
1.1 Biophilic Regulation Systems
1.1.1	[56]	Visual, Auditory, Tactile	Enhances emotional expression and interpersonal relationships in individuals with sensory disorders	Enhances emotional expression and interpersonal relationships in individuals with sensory disorders	No
1.1.2	[57]	Visual, Auditory, Tactile	Detachable stamp, circular reader, wall beam projector with image inpainting technology	Enhances sensory development and mental well-being by facilitating interactive engagement with nature	No
1.1.3	[45]	Visual, Ambient Light	Embedded LED light strips within cloud-shaped wall panels	Creates a comforting natural environment with soft, warm lighting simulating a bright blue sky to soothe pediatric patients	Yes
1.2 Acoustic Modulation Technologies
1.2.1	[55]	Auditory, Visual	Augmented Reality (AR), Gamification, Music Therapy	Aims to improve symptoms of mild autism in children through a gamified music therapy application	Yes
1.2.2	[58]	Visual, Motor, Auditory	Tilted base, handles, glowing rings with brightness changes when rotating	Encourages physical exercise and exploration through rhythmic dance, enhancing motor skills and social interaction	No
1.2.3	[59]	Auditory, Visual	Smart audio player, AR figurine, companion app	Provides children with their first experience of an internet-based audio player and app in a safe and playful manner, stimulating auditory and cognitive development	No

For detailed project numbers, see Figure 3.

Table 2. Evaluation Framework of Sensory Feedback Design (generated by the authors).

Project	Source	Sensory	Description	Therapeutic Role	Validation
1.1 Biophilic Regulation Systems
1.1.1	[56]	Visual, Auditory, Tactile	Enhances emotional expression and interpersonal relationships in individuals with sensory disorders	Enhances emotional expression and interpersonal relationships in individuals with sensory disorders	No
1.1.2	[57]	Visual, Auditory, Tactile	Detachable stamp, circular reader, wall beam projector with image inpainting technology	Enhances sensory development and mental well-being by facilitating interactive engagement with nature	No
1.1.3	[45]	Visual, Ambient Light	Embedded LED light strips within cloud-shaped wall panels	Creates a comforting natural environment with soft, warm lighting simulating a bright blue sky to soothe pediatric patients	Yes
1.2 Acoustic Modulation Technologies
1.2.1	[55]	Auditory, Visual	Augmented Reality (AR), Gamification, Music Therapy	Aims to improve symptoms of mild autism in children through a gamified music therapy application	Yes
1.2.2	[58]	Visual, Motor, Auditory	Tilted base, handles, glowing rings with brightness changes when rotating	Encourages physical exercise and exploration through rhythmic dance, enhancing motor skills and social interaction	No
1.2.3	[59]	Auditory, Visual	Smart audio player, AR figurine, companion app	Provides children with their first experience of an internet-based audio player and app in a safe and playful manner, stimulating auditory and cognitive development	No

For detailed project numbers, see Figure 3.

Behavioral Guidance Design

Behavioral guidance design supports children in expressing and regulating emotions during therapy through the interactivity and directive nature of spatial elements. Interactive art installations and guiding spatial features encourage children to engage in behaviors such as movement and touch, fostering unconscious actions that contribute to emotional regulation and therapeutic outcomes. These design elements help transform children’s beliefs into positive emotions, thereby reducing medical anxiety, and into positive behaviors, thereby enhancing compliance.

The conceptual foundation of behavioral guidance design draws upon several established psychological and neurological theories. From the perspective of environmental psychology, structured and engaging physical environments can significantly influence children’s behavior and emotional responses by providing cues for action and affective comfort [60]. Behavioral therapy principles emphasize the role of stimuli and reinforcements in shaping desirable behaviors, which interactive installations and responsive devices can provide in real-time [61]. Furthermore, affective neuroscience research shows that multisensory stimuli, such as light, sound, and tactile feedback, activate brain regions responsible for emotional regulation, including the amygdala and prefrontal cortex [62]. These theoretical underpinnings validate the use of spatial interactivity and intelligent sensing technologies to support behavioral modification and emotional self-regulation, particularly in children with autism who may experience difficulties in communication and affective processing. The structural case descriptions are presented in Table 3.

• Art Installations: At the “Flower of Life” integrated clinic in Vladivostok, a therapeutic environment is designed to balance playfulness with medical professionalism. The space is conceptualized as a tangible “children’s town”, where architectural and spatial elements encourage exploration and engagement. Interactive features such as paper boats and lighthouse track installations on the walls provide playful distractions for children in waiting areas, helping to alleviate anxiety and redirect attention in a calming, engaging manner [63]. These installations function as cognitive regulators: by drawing attention through movement and symbolic imagery, they help reduce hypervigilance and promote relaxation, particularly in children with ASD who often experience heightened anxiety in clinical settings.
  In our design of the International Medical Department of Shanghai Children’s Medical Center, our team incorporated interactive projection technology to enrich the healing environment. Pediatric patients engage with three core themes (nature education, traffic safety, and energy sustainability) through playful gestures and body movement. The interactive experience not only transforms passive waiting time into active exploration but also enhances sensory integration and executive functioning. For children with ASD, such spatial interactions have been shown to improve joint attention, motor coordination, and cognitive flexibility, which are crucial for adaptive behaviors.
• Motion-Sensing Devices: Through the integration of infrared sensors, motion capture technologies (such as Kinect), and depth cameras, children’s movements can be accurately detected and analyzed. LED lighting and dynamic projection systems respond in real time to specific behaviors, such as walking, pausing, or gesturing, by adjusting light intensity, color, and projected content. This responsive interaction forms a feedback loop that encourages self-awareness and behavior modulation. A representative example is LUMES at Cabrini Hospital, which utilizes pressure sensors to detect changes in children’s gait and generates colorful light paths in response. Such dynamic feedback not only attracts children’s attention but also serves as a structured platform for emotional regulation and sensory engagement. For children with ASD, this type of cause-and-effect interaction fosters predictability and reinforces behavioral responses, thereby supporting therapeutic goals related to attention, emotional control, and social participation [64].
• Robotic Interaction: Robotic technology has shown promise in supporting children with ASD by enhancing their social skills and emotional expression [65]. Children with autism often face significant challenges in social interactions, such as making eye contact, expressing emotions, and interpreting social cues. Assistive robots simulate human behaviors and emotional responses in a consistent and non-threatening way, creating a safe environment for repeated practice. This predictable and low-pressure setting reduces social anxiety and allows children to gradually develop communication and interpersonal skills at their own pace [66]. Game-based robotic interventions used in art therapy sessions, for example, have been shown to promote social initiation and sustained engagement. Through structured dyadic interactions, robots offer clear feedback, emotional mirroring, and turn-taking opportunities, elements that are crucial for children with ASD to improve joint attention, reciprocal interaction, and emotional regulation [67]. These design features contribute to measurable therapeutic outcomes, such as increased eye contact, verbal initiation, and improved affect recognition, aligning closely with core goals of ASD intervention programs.

Table 3. Evaluation Framework of Behavioral Guidance Design (generated by the authors).

Project	Source	Sensory	Description	Therapeutic Role	Validation
2.1 Art Installations
2.1.1	[63]	Visual, Tactile	Interactive spatial design (seating in greenery, interactive interiors)	Create a balanced space between playfulness and medical formality; engage children during waiting times	No
2.1.2	[68]	Visual, Tactile, Emotional	Wall painting, decorative installations, environmental theming (sunlight, forest, animals)	Reduce children’s fear of clinical treatment; provide emotionally comforting and engaging environment	No
2.1.3	[69]	Visual, Auditory, Tactile	Vibration sensors, light-emitting devices, audio systems	Facilitate social contact for autistic children; make physical interaction enjoyable and low-pressure	No
2.2 Motion-Sensing Devices
2.2.1	[64]	Visual, Tactile	Motion sensors, LED digital wall, animation triggers	Enhance mood in pediatric wards; delight children with interactive animations (animals, landscapes)	No
2.1.2	[70]	Visual, Tactile	5 interactive totems, giant double-sided screens, virtual projection technology	Guide imaginative journeys; support emotional expression and regulation; make treatment more comfortable	No
2.3 Robotic Interaction
2.3.1	[71]	Visual, Auditory, Tactile	Advanced language/emotion recognition, AR interactive projection, multiple sensors	Provide personalized social skills training; build emotional resonance; enhance self-awareness in social contexts	No

For detailed project numbers, see Figure 3.

Table 3. Evaluation Framework of Behavioral Guidance Design (generated by the authors).

Project	Source	Sensory	Description	Therapeutic Role	Validation
2.1 Art Installations
2.1.1	[63]	Visual, Tactile	Interactive spatial design (seating in greenery, interactive interiors)	Create a balanced space between playfulness and medical formality; engage children during waiting times	No
2.1.2	[68]	Visual, Tactile, Emotional	Wall painting, decorative installations, environmental theming (sunlight, forest, animals)	Reduce children’s fear of clinical treatment; provide emotionally comforting and engaging environment	No
2.1.3	[69]	Visual, Auditory, Tactile	Vibration sensors, light-emitting devices, audio systems	Facilitate social contact for autistic children; make physical interaction enjoyable and low-pressure	No
2.2 Motion-Sensing Devices
2.2.1	[64]	Visual, Tactile	Motion sensors, LED digital wall, animation triggers	Enhance mood in pediatric wards; delight children with interactive animations (animals, landscapes)	No
2.1.2	[70]	Visual, Tactile	5 interactive totems, giant double-sided screens, virtual projection technology	Guide imaginative journeys; support emotional expression and regulation; make treatment more comfortable	No
2.3 Robotic Interaction
2.3.1	[71]	Visual, Auditory, Tactile	Advanced language/emotion recognition, AR interactive projection, multiple sensors	Provide personalized social skills training; build emotional resonance; enhance self-awareness in social contexts	No

For detailed project numbers, see Figure 3.

Emotional Resonance Design

Emotional resonance design focuses on building deep emotional connections with children, helping them release emotions, reduce anxiety, and express feelings through interaction with the environment. These design elements adapt to children’s emotional needs and physiological responses, offering personalized therapeutic support. Emotional resonance can be directly triggered through sensory stimulation or emotional connection, effectively alleviating anxiety and enhancing emotional engagement. Technologies such as affective computing, biofeedback systems, and interactive art installations can facilitate deeper emotional connections between children and their environment. These approaches are particularly effective for children with autism who experience difficulties in emotional expression and regulation. The structural case descriptions are presented in Table 4.

• Physiological Signal Sensing: By monitoring physiological indicators such as electrodermal activity (EDA), heart rate, and EEG signals, systems can detect real-time changes in children’s emotional states and respond adaptively. Wearable sensors, such as the Spire Stone, integrate advanced analytics and continuous physiological monitoring to support clinical decision-making, particularly in cardiopulmonary care [72]. While the device itself does not directly adjust environmental conditions, it provides caregivers with valuable real-time data, such as signs of elevated anxiety, which can inform interventions like dimming lights or reducing noise to support emotional regulation. These effects are increasingly being verified through behavioral indicators (e.g., reduced agitation and improved focus) and follow-up assessments. Computer vision technologies, combined with deep learning, can analyze facial expressions to infer emotions in real time [73], and systems like FaceReader quantitatively classify emotional states using facial action units [74,75]. These emotional insights can be translated into visual or auditory feedback, such as avatar mirroring or adaptive music, that enhances engagement. Under controlled design conditions, such as minimizing sensory overload, aligning feedback with detected emotional shifts, and ensuring low-latency responses, these technologies reliably support children’s emotional awareness and expression.
• Embodied Affective Intelligence: Emerging technologies externalize emotional states and support expression through embodied interaction. Devices like the Myo armband translate electromyographic (EMG) signals into digital outputs, enabling children to control visual feedback with body movements, thereby connecting internal arousal with external creative expression. This embodied form of emotional representation helps children, especially those with ASD or communication difficulties, to visualize and regulate their feelings. Tactile interventions, such as the SAD Light Therapy Pillow [76], combine sensory comfort with light-based affective signaling, creating emotionally safe environments. Installations like Oscillation 2020 [77] provide real-time, audio-reactive visuals that translate sensory input into immersive digital landscapes. In these cases, emotional effects are not merely assumed, they are designed to emerge through multisensory coherence, personalization, and active user control, which are key design conditions known to support sustained emotional engagement in therapeutic and educational settings.

• Narrative Systems: Dramatherapy leverages a variety of artistic methods and techniques to foster behavioral development, expressive abilities, and social skills, while also supporting emotional well-being in children with ASD [78]. In this context, narrative-driven healing spaces are playing an increasingly important role in the art therapy environment for autistic children. A notable example is found at Ibaraki Prefectural Children’s Hospital in Japan, where a story-centered design was implemented around two original characters: Lala and Coco the sea otters. Illustrated murals and art installations in the style of picture books were embedded throughout waiting and transitional areas, creating an immersive environment referred to as “Lala and Coco’s Hometown.” This child-centric storytelling approach aims to reduce anxiety, cultivate a sense of emotional safety, and foster engagement through exploratory, immersive play [79].

• Virtual Reality Technology: VR has shown considerable potential in enhancing emotional and social functioning in children with ASD [80,81]. With the increasing accessibility of mobile internet and VR devices, recent designs have incorporated virtual environments to allow children to practice emotional expression and social communication in safe, controllable settings. These tools enable personalized, adaptive interventions with real-time behavioral feedback, helping children develop emotional regulation and behavioral self-awareness [82].
  A growing body of research has supported the efficacy of VR-based therapeutic systems. For example, Horace H.S. Ip et al. [83] implemented a multi-cue, scenario-based VR intervention across six daily-life situations, showing significant improvements in emotional expression, social reciprocity, and behavioral compliance in children with ASD. Similarly, Minyue Zhang et al. [84] found that VR-enhanced learning environments effectively improved emotion recognition accuracy and engagement levels among children with autism when compared to traditional video-based interventions. These systems utilize immersive stimuli (e.g., avatars, contextual storytelling, and environmental cues) to simulate real-life social dynamics while maintaining sensory safety, making them particularly suitable for children with sensory sensitivities.
  Together, these studies suggest that VR is not only a medium for rehearsal but also a structured, customizable therapeutic environment. Its success appears closely tied to key design conditions, such as context realism, emotional congruency, multisensory coherence, and repetition frequency. A more critical engagement with this body of research strengthens the theoretical foundation for integrating VR into future ASD therapeutic strategies.

Table 4. Evaluation Framework of Emotional Resonance Design (generated by the authors).

Project	Source	Sensory	Description	Therapeutic Role	Validation
3.1 Physiological Signal Sensing
3.1.1	[72]	Physiological signals, Visual	Wearable sensor, data transmission to app for analysis	Predict modeling, enable timely intervention, improve designer-patient relationship, support proactive emotional health management	No
3.2 Embodied Affective Intelligence
3.2.1	[76]	Visual, Tactile	LED light source, sensor for usage tracking	Transform 40W treatment lamp into engaging experience, combine comfort and emission, support mood disorder treatment	No
3.2.2	[77]	Visual, Auditory	Audio-to-visual conversion technology, interactive projection	Encourage emotional engagement by making users alter digital landscapes, connect more profoundly with moment	No
3.3 Narrative Systems
3.3.1	[79]	Visual, Tactile	Wall-based story-themed installations, illustrative design	Ease anxiety, foster emotional comfort through immersive, exploratory play	No
3.2.2	[85]	Visual, Tactile	Custom wall sculptures, thematic design	Spark imagination, discuss, encourage dialogue, engagement in medical setting	No
3.4 Virtual Reality Technology
3.4.1	[83]	Visual, Tactile, Auditory	4-side immersive VR setup (semi-CAVE), motion-tracking, VR content delivery	Provide VR environment for ASD children, likely for skill-growth, emotional training through immersive experience	Yes

For detailed project numbers, see Figure 3.

Table 4. Evaluation Framework of Emotional Resonance Design (generated by the authors).

Project	Source	Sensory	Description	Therapeutic Role	Validation
3.1 Physiological Signal Sensing
3.1.1	[72]	Physiological signals, Visual	Wearable sensor, data transmission to app for analysis	Predict modeling, enable timely intervention, improve designer-patient relationship, support proactive emotional health management	No
3.2 Embodied Affective Intelligence
3.2.1	[76]	Visual, Tactile	LED light source, sensor for usage tracking	Transform 40W treatment lamp into engaging experience, combine comfort and emission, support mood disorder treatment	No
3.2.2	[77]	Visual, Auditory	Audio-to-visual conversion technology, interactive projection	Encourage emotional engagement by making users alter digital landscapes, connect more profoundly with moment	No
3.3 Narrative Systems
3.3.1	[79]	Visual, Tactile	Wall-based story-themed installations, illustrative design	Ease anxiety, foster emotional comfort through immersive, exploratory play	No
3.2.2	[85]	Visual, Tactile	Custom wall sculptures, thematic design	Spark imagination, discuss, encourage dialogue, engagement in medical setting	No
3.4 Virtual Reality Technology
3.4.1	[83]	Visual, Tactile, Auditory	4-side immersive VR setup (semi-CAVE), motion-tracking, VR content delivery	Provide VR environment for ASD children, likely for skill-growth, emotional training through immersive experience	Yes

For detailed project numbers, see Figure 3.

Therapeutic Support Design

Therapeutic support design plays an auxiliary role in the rehabilitation process by reinforcing therapeutic outcomes. By leveraging multimodal technologies to stimulate children’s sensory and emotional responses, this design approach helps form positive beliefs, which in turn lead to improved emotional states and behavioral outcomes. It provides individualized support tailored to the unique needs of children with autism, ensuring a more comprehensive and sustainable healing experience. The structural case descriptions are presented in Table 5.

• Tactile Rehabilitation Support: Ultrasonic array technology can be employed to simulate diverse tactile feedback, offering children with autism a variety of touch experiences. This approach enables children, especially those with tactile hypersensitivity, to gradually acclimate to different sensory stimuli. While waiting, patients and their caregivers can interact with nature-themed animated projections on hospital room walls using simple physical controllers. These immersive natural scenes help reduce anxiety and promote emotional calm [86].
• Intelligent Therapeutic Devices: These include AI-integrated therapeutic robots and wearable devices that provide personalized treatment recommendations or behavioral training based on the child’s physiological and emotional states. For example, virtual companion robots assist children in practicing daily emotional expression and social interaction skills. The BrainCo brain–computer interface social communication training system enhances interest and engagement through gamified exercises, effectively cultivating social communication abilities in children with autism [87].
• Therapeutic Rehabilitation and Companionship: AI technologies analyze children’s facial expressions, voice, and body language to identify emotional states in real-time, providing therapists immediate feedback [46]. Big Pal, a social robot for autistic children, offers multisensory interaction training and cloud-based evaluation for data analysis, supporting therapists and alleviating medical resource pressure [93]. Peking University Health’s A-PKU system enables multi-scenario educational rehabilitation through intelligent platforms [88]. Core Education’s CareTAI provides full-cycle rehabilitation management from assessment to training, supporting institutional administration and home-school collaboration [89]. CETC’s Cognitive Psychology and Attention Rehabilitation System offers 300+ interactive courses with offline materials for children aged 0–14, applied in hospitals, special schools, and rehabilitation centers [90].

Table 5. Evaluation Framework of Therapeutic Support Design (generated by the authors).

Project	Source	Sensory	Description	Therapeutic Role	Validation
4.1 Intelligent Therapeutic Devices
4.1.1	[87]	EEG, Auditory, Tactile	EEG monitoring, AI analysis, sound therapy, cranial stimulation technology	Monitor brain activity, guide relaxation, improve sleep quality, provide stress relief	No
4.1.2	[91]	Temperature sensing, Tactile	Bluetooth temperature tracking, smartphone alert system, ergonomic design	Track real-time temperature, send alerts, enable remote health monitoring for parents	No
4.1.3	[92]	Visual, Tactile	Optical and IoT technology, app-based control, personalized accessories integration	Offer non-surgical strabismus treatment, support customized, comfortable use for patients	No
4.2 Therapeutic Rehabilitation Companionship
4.2.1	[93]	Visual, Auditory, Tactile	Programmable robotics, social/emotional interaction algorithms, customizable interactions	Support social, emotional, behavioral learning in autistic children, reduce anxiety, boost engagement	No
4.2.2	[89]	Visual, Auditory	Full-cycle digital management system, data tracking, home-school collaboration platform	Manage children’s rehabilitation (tests, assessments, IEP planning, etc.), enable data-driven care	No
4.3 Tactile Rehabilitation Support
4.3.1	[94]	Tactile, Visual	Vibrotactile garment with embedded emotional cues, memory-related interactive design	Aid emotional communication, serve as complementary tool for memory engagement, emotional understanding	Yes

For detailed project numbers, see Figure 3.

Table 5. Evaluation Framework of Therapeutic Support Design (generated by the authors).

Project	Source	Sensory	Description	Therapeutic Role	Validation
4.1 Intelligent Therapeutic Devices
4.1.1	[87]	EEG, Auditory, Tactile	EEG monitoring, AI analysis, sound therapy, cranial stimulation technology	Monitor brain activity, guide relaxation, improve sleep quality, provide stress relief	No
4.1.2	[91]	Temperature sensing, Tactile	Bluetooth temperature tracking, smartphone alert system, ergonomic design	Track real-time temperature, send alerts, enable remote health monitoring for parents	No
4.1.3	[92]	Visual, Tactile	Optical and IoT technology, app-based control, personalized accessories integration	Offer non-surgical strabismus treatment, support customized, comfortable use for patients	No
4.2 Therapeutic Rehabilitation Companionship
4.2.1	[93]	Visual, Auditory, Tactile	Programmable robotics, social/emotional interaction algorithms, customizable interactions	Support social, emotional, behavioral learning in autistic children, reduce anxiety, boost engagement	No
4.2.2	[89]	Visual, Auditory	Full-cycle digital management system, data tracking, home-school collaboration platform	Manage children’s rehabilitation (tests, assessments, IEP planning, etc.), enable data-driven care	No
4.3 Tactile Rehabilitation Support
4.3.1	[94]	Tactile, Visual	Vibrotactile garment with embedded emotional cues, memory-related interactive design	Aid emotional communication, serve as complementary tool for memory engagement, emotional understanding	Yes

For detailed project numbers, see Figure 3.

3.3.2. Technological Map of the Responsive Therapeutic Environments

The application of intelligent spatial technologies creates responsive therapeutic environments that utilize smart environmental sensing systems to trigger art therapy interactions, thereby better adapting to the emotional and therapeutic needs of patients [34]. Responsive therapeutic environment emphasizes not only the functionality and comfort of the space but also the coordination of emotional connection and sensory stimulation, adapting effectively to individual needs while providing therapeutic support [44].

Building upon the conceptual framework established above, the practical implementation of responsive therapeutic environments requires a comprehensive integration of emerging technologies that can support each component of the proposed framework. Based on the review of current technological applications, various innovative technologies have been identified and categorized according to their primary functions and application domains. The classification and mapping of these technologies are summarized in

Table 6. Technological map of responsive therapeutic environments (generated by the authors).

Design	Technology	Specific Technologies
SF	Biophilic Regulation Systems	Smart Lighting Systems, Natural Sound Systems
	Acoustic Modulation Technologies	Spatial Audio Systems, Noise Cancellation Devices
BG	Art Installations	Interactive Projection Systems, Art installation design
	Motion-Sensing Devices	LiDAR Sensors, Computer Vision Systems
	Robotic Interaction	Social Robots, Therapeutic Companion Robots
ER	Physiological Signal Sensing	Heart Rate Monitors, EEG, Skin Conductance Sensors
	Embodied Affective Intelligence	Emotion Recognition Sensor, Facial Expression Analysis
	Narrative Systems	Interactive Storytelling Platforms, Digital Art Installations
	Virtual Reality Technology	VR Headsets, Immersive Projection
TS	Tactile Rehabilitation Support	Ultrasonic array
	Intelligent Therapeutic Devices	AI-Powered Therapy Tools, Adaptive Interface Systems
	Therapeutic Rehabilitation	Biofeedback Systems, Motor Skill Training Devices
	Companionship	Social Companion Robots, AI Chatbots

Design elements symbols: SF: sensory feedback; BG: behavioral guidance; ER: emotional resonance; TS: therapeutic support.

, providing a structured overview of how different systems align with either environmental or user-centered applications.

The framework emphasizes that successful technology integration requires careful balance between innovation and therapeutic integrity, with technology functioning as a mediator rather than a driver of therapeutic processes. In practice, this means technologies should enhance rather than replace human connections, for example, using interactive projection systems that encourage therapist–child collaboration rather than isolating digital interfaces that redirect attention away from human interaction. Similarly, technology should support rather than direct creative expression by providing adaptive tools that respond to individual creative choices rather than prescriptive programs that impose predetermined outcomes.

However, over-reliance on technology in therapeutic contexts can be problematic. For instance, while VR environments may offer controlled sensory experiences, excessive dependence on virtual settings might inhibit children’s ability to develop coping strategies for real-world sensory challenges. Therefore, designers must assess whether each technological element enhances or inhibits emotional, behavioral, and sensory engagement by evaluating concrete metrics such as duration of social interaction, spontaneous communication attempts, and transfer of skills to non-technological contexts. This approach ensures that technological advancement serves the ultimate goal of improving therapeutic outcomes for children with autism while maintaining the primacy of human-centered therapeutic relationships.

3.3.3. Design Principles of the Responsive Therapeutic Environments

These evidence-based principles provide a theoretical framework for developing responsive therapeutic environments that can systematically address the complex and individualized needs of children with autism in art therapy settings, grounded in environmental psychology, behavioral therapy, and affective neuroscience theories [60,61].

First, centering the child’s experience and agency [95] requires that environmental responsiveness be calibrated to amplify rather than override the child’s autonomous creative expression and individual therapeutic trajectories [96]. This principle aligns with person-centered approaches that recognize the importance of self-determination in autism interventions [97]. Environmental elements should respond to children’s emotional states while maintaining their agency in the art-making process, supporting the Emotion component of our framework through positive belief formation.

Second, promoting multisensory and non-verbal expression acknowledges the documented preference for sensory and artistic communication modalities among children with autism spectrum disorders [98,99]. Responsive environments should therefore integrate multiple sensory channels and provide diverse expressive outlets that accommodate varied communication styles and sensory processing differences [100,101]. This operationalizes both Sense and Behavior components by providing diverse pathways for environmental perception and behavioral engagement.

Finally, integrating technology as a mediator rather than a driver ensures that technological elements serve to enhance human connection and facilitate natural creative processes rather than replacing them [102]. This approach recognizes the importance of maintaining therapeutic relationships while leveraging technology’s capacity for environmental responsiveness [103,104]. Technology as mediator is characterized by supporting therapeutic goals, enhancing artistic expression, and maintaining human connection through features like environmental adjustment based on emotional states or interactive projection that enriches rather than replaces art creation. In contrast, technology as a driver problematically becomes the primary focus, creates learning barriers, or causes sensory overload. This principle draws upon applied behavior analysis research demonstrating the effectiveness of immediate environmental feedback in therapeutic contexts [105,106].

4. Discussion

4.1. Interpretation of Results

Our dual-track analysis reveals a systematic pathway for technology integration in autism art therapy environments. The bibliometric analysis identified ten primary research clusters that were conceptualized into four core design elements, while case study analysis validated these elements and provided practical implementation insights. This convergence demonstrates how literature-derived knowledge can be translated into actionable design strategies.

Three key outcomes emerged from this study. First, based on the clustering results obtained from bibliometric analysis and the ground of the ABC model from positive psychology theory, a new framework for therapeutic environment design for ASD children was constructed. Second, by combining the design elements derived from bibliometric cluster analysis with case analysis, explore how different design elements are effectively designed, and then summarize the design guiding principles. Third, identify the opportunities for integrating healing environments and emerging technologies from the hotspots presented in the bibliometric analysis. Then, combined with case analysis, summarize the design technology map.

4.2. Contributions

4.2.1. Theoretical Contributions

Current design approaches in art therapy environments that emphasize immediate sensory feedback and engagement enhancement often overlook the genuine long-term developmental needs of children with autism during creative expression, including independent artistic exploration, non-verbal communication through art, and emotional regulation during creative processes [14,15,18]. Traditional therapeutic environments often lack flexibility and personalization, failing to respond promptly to children’s emotional and behavioral changes during activities. For the design of art therapy environments for children with autism, it is of utmost importance to focus on the behavioral therapy and emotions of these children. This emphasis not only addresses the shortcomings of traditional settings but also forms the cornerstone for the development of the proposed framework, enabling it to be more responsive, individualized, and ultimately more effective in meeting the unique needs of autistic children during the art therapy process.

The proposed responsive therapeutic environment framework directly addresses several critical challenges in the current autism art therapy environment design practice. Traditional therapeutic environments typically suffer from a disconnect between design professionals and clinical expertise, often resulting in spaces that prioritize aesthetic appeal over evidence-based therapeutic objectives specific to art therapy interventions [14,15]. Our framework bridges this gap by establishing clear connections between environmental design elements and positive behavioral art therapy outcomes through the emotion–sense–environment–behavior model. The integration demonstrates how architectural environmental parameters systematically influence therapeutic outcomes through an established psychological framework, providing a scientific foundation for environmental therapy and opening new theoretical pathways for evidence-based design practice [42].

This framework integrates the ABC model into a comprehensive therapeutic design system where the activating event triggers the child’s interaction with a carefully designed environment. The framework operates as a dynamic feedback loop where consequences continuously inform and reshape the belief system, which in turn influences how future activating events are processed. Emotional resonance design serves as the central integrative mechanism, ensuring that sensory processing, therapeutic interventions, and behavioral guidance work synergistically to create positive therapeutic outcomes. This cyclical nature allows for adaptive refinement of the therapeutic environment based on real-time emotional and behavioral feedback.

4.2.2. Practical Implications

From a practical perspective, this framework directly addresses several critical challenges in the current autism art therapy environment design practice. Traditional therapeutic environments typically suffer from a disconnect between design professionals and clinical expertise, often resulting in spaces that prioritize aesthetic appeal over evidence-based therapeutic objectives specific to art therapy interventions. Furthermore, emerging technologies such as VR systems and wearable devices often present substantial learning costs and challenging patient compliance issues in art therapy contexts [16,17]. Our framework addresses this by positioning technology as a mediator that enhances artistic expression and creative exploration, not a driver that overwhelms the therapeutic art-making process, ensuring that technological integration supports rather than interferes with children’s natural creative impulses and artistic development.

The responsive therapeutic environment proposed in this study addresses these limitations through key design principles that specifically support art therapy objectives. Multisensory design integrates multiple sensory inputs such as visual, auditory, and tactile stimuli to provide a multidimensional therapeutic experience, activating different areas of the brain and improving sensory integration abilities [107]. Emotional resonance and narrativity create environments that help children establish emotional connections with the therapeutic space through narrative elements, promoting self-awareness and emotional expression [108]. Interactivity and immersion employ advanced technologies to enhance deep perceptual engagement beyond mere physical participation [23,27]. Personalization and adaptability ensure that environmental elements can automatically adjust based on individual emotional states and therapeutic goals [44].

The framework provides systematic design guidance for interdisciplinary teams including environmental designers, clinical practitioners, technology developers, and healthcare administrators. This contributes to creating more effective environmental spaces for art therapy activities for children with autism, ensuring that technological integration supports rather than interferes with children’s natural creative impulses and artistic development.

4.3. Limitations

This review acknowledges several methodological and practical limitations that may have influenced our findings. The literature selection strategy, while systematic, presents certain constraints. The primary reliance on Web of Science databases and English-language publications may have inadvertently excluded valuable regional research and culturally specific design approaches that could offer unique insights into responsive therapeutic environments [109,110]. This limitation is particularly significant given that autism intervention practices and environmental design philosophies vary considerably across different cultural contexts [111,112]. Furthermore, our focus on journal articles may have under-represented clinical art therapy research that employs less technologically-mediated approaches, potentially overlooking innovative low-tech or culturally grounded therapeutic strategies [113].

Case selection limitations also warrant consideration. The reviewed studies predominantly feature completed implementation cases, lacking consideration of forward-thinking conceptual designs and emerging theoretical frameworks. This bias toward realized projects may limit understanding of innovative conceptual designs that remain unimplemented due to technological, financial, or regulatory constraints [114].

Despite the promising potential of responsive therapeutic environments, several practical limitations must be acknowledged. First, the implementation of intelligent sensing systems and adaptive technologies requires substantial financial investment and technical expertise, potentially limiting accessibility for many therapeutic facilities. The complexity of integrating multiple technologies while maintaining user-friendly interfaces poses ongoing challenges for practitioners without specialized technical training. Second, the highly personalized nature of ASD means that environmental responses effective for one child may not be appropriate for another [115]. While the framework emphasizes adaptability, developing truly individualized environments requires extensive assessment and calibration processes that may be time-consuming and resource-intensive.

Additionally, privacy and ethical considerations surrounding the use of sensing technologies to monitor children’s emotional and behavioral states require careful attention. Balancing therapeutic benefits with respect for individual autonomy and data protection presents ongoing challenges that must be addressed through collaborative efforts between designers, clinicians, and ethicists.

4.4. Future Research Directions

Future research should prioritize longitudinal studies to establish the sustained impact of responsive therapeutic environments on children with autism across different developmental stages [49,116]. Comparative effectiveness research comparing responsive environments with traditional therapeutic settings will be essential for validating the framework’s clinical value [33].

The development of standardized assessment tools for measuring environmental responsiveness and therapeutic effectiveness remains a critical need [23]. Such tools should incorporate both quantitative metrics (behavioral observations and physiological responses) and qualitative measures (child and family experiences and therapist perspectives) to provide comprehensive evaluation frameworks [117].

Interdisciplinary collaboration between design professionals, clinical practitioners, technology developers, and autism researchers should be strengthened to ensure that future innovations remain grounded in evidence-based practice [51]. Establishing design guidelines and best practices for responsive therapeutic environments will facilitate broader adoption and implementation across diverse therapeutic contexts.

Finally, research into cost-effective implementation strategies and scalable technology solutions will be crucial for making responsive therapeutic environments accessible to a broader population of children with autism. This includes exploring partnerships between educational institutions, healthcare systems, and technology companies to support sustainable development and deployment of innovative therapeutic environments that can be widely adopted across diverse clinical and educational settings.

5. Conclusions

Art therapy is a therapeutic approach that fosters mental health and emotional expression through creative art forms such as painting, music, and dance [118]. The core characteristics of ASD encompass challenges in social communication, difficulties in emotional regulation, and behavioral disturbances, all of which substantially constrain the emotional expression and social interaction capabilities of children with autism [119,120]. By integrating artistic creation with psychotherapy, it utilizes art media to assist individuals in expressing their subconscious emotions and experiences, thereby facilitating healing and self-exploration [121]. The application of art therapy in the treatment of autism has garnered widespread recognition and scholarly investigation.

Aiming to optimize technology integration while preserving therapeutic integrity, this study demonstrates that effective technology integration requires structured evaluation frameworks that distinguish between technology as a therapeutic mediator and a disruptive driver. The four-step research progression, from cluster identification to design element conceptualization, framework validation, and principle formulation, provides a replicable methodology for technology assessment and integration in therapeutic contexts.

Key contributions encompass a design framework for therapeutic environment, evidence-based design principles that prioritize child-centeredness and multisensory expression while maintaining appropriate technology integration, and a technology map categorizing available technologies according to their therapeutic functions and implementation requirements.

The proposed emotion–sense–environment–behavior model bridges critical gaps between environmental design and clinical practice, offering systematic guidance for creating therapeutic spaces that enhance emotional regulation, sensory integration, and social communication for children with ASD. The four core design elements (sensory feedback, behavioral guidance, emotional resonance, and therapeutic support) provide a foundation for developing sustainable healthcare environments adaptable across diverse cultural and economic contexts.

This research establishes a comprehensive evidence-based framework for responsive therapeutic environments in autism art therapy, directly contributing to SDG3 (good health and well-being) through the advancement of inclusive, effective therapeutic interventions. The convergence of literature-based and case-based data foundations enables comprehensive cross-validation of findings, enhancing analytical depth by combining theoretical insights with empirical evidence.

The framework directly addresses SDG3.4 by promoting mental health through evidence-based environmental interventions that support emotional regulation, SDG3.8 through cost-effective, scalable design solutions that make quality therapeutic environments more accessible across diverse socioeconomic settings, and SDG3.c by providing guidance for efficient resource allocation and infrastructure development. The interdisciplinary approach aligns with SDG17 (partnerships for the goals), fostering collaboration between designers, clinicians, technologists, and healthcare administrators.

Future applications should focus on longitudinal validation studies and the development of standardized assessment tools for measuring technology’s therapeutic effectiveness. The framework’s emphasis on technology as mediator rather than driver provides a sustainable pathway for integrating emerging technologies while preserving the fundamental human connections that make art therapy uniquely powerful for children with autism, ensuring that technological advancement serves therapeutic goals rather than becoming an end in itself.