Received: 22 January 2024 Revised: 13 July 2024 Accepted: 30 July 2024

DOI: 10.1111/fare.13092

RESEARCH

Family-centered creative arts therapies for children

with autism: A configurative systematic review

Janet Tein Ni Moo 1 | Rainbow Tin Hung Ho 2

1
Department of Social Work & Social Abstract
Administration, The University of Hong
Kong, Centennial Campus, Pokfulam,
Objective: This configurative systematic review analyzed
Hong Kong family-centered creative arts therapies for children with
2
Centre on Behavioral Health, The University autism to understand why and how they are done.
of Hong Kong, Pokfulam, Hong Kong Background: Creative arts therapies and family-centered
practice are both beneficial for children with autism.
Correspondence
Research combining both approaches—that is, family-cen-
Rainbow Tin Hung Ho, Centre on Behavioral
Health, The University of Hong Kong, 2/F, tered creative arts therapies—is emerging, and reported
The Hong Kong Jockey Club Building for findings are promising. A deeper understanding of the the-
Interdisciplinary Research, 5 Sassoon Road,
oretical influences and mechanisms of these therapies may
Pokfulam, Hong Kong.
Email: [email protected] generate new ways of thinking and working with families
with children with autism.
Methods: Following registration with PROSPERO and in
accordance with PRISMA (Preferred Reporting Items for
Systematic Reviews and Meta-Analyses) guidelines, a liter-
ature search was performed, resulting in 17 studies. The-
matic analysis considered the studies in terms of theoretical
influences, creative arts therapy components, and family-
centered components.
Results: The development-in-context perspective was a key
theoretical influence. In addition to music and singing,
body movement/physical activity was a prominent compo-
nent of creative arts therapies. Verbal support as well as
modeling behaviors and strategies to parents were salient
family-centered components.
Conclusion: This systematic review reveals common princi-
ples, practices, and gaps in the existing literature and their
relevance for families with children with autism.
Implications: These findings bear implications for families,
therapists, Certified Family Life Educators, and other pro-
fessionals working with families with children with autism.

Author note: We thank Alhassan Abdullah for his help with auditing the data analyses.The data that support the findings of this study
are available from the corresponding author upon reasonable request.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits
use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or
adaptations are made.
© 2024 The Author(s). Family Relations published by Wiley Periodicals LLC on behalf of National Council on Family Relations.

412 wileyonlinelibrary.com/journal/fare Family Relations. 2025;74:412–429.

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FAMILY-CENTERED CREATIVE ARTS THERAPIES AND AUTISM 413

KEYWORDS
autism, creative arts therapies, dance movement, family-centered, music,
neurodiversity

Creative arts therapies (CATs) and family-centered practice have each been found to be helpful
for children with autism. The evidence base is growing, for both CATs (e.g., Bololia
et al., 2022; Takahashi et al., 2019) and family-centered practice (e.g., Coogle & Hanline, 2014;
Watling et al., 2023). Their respective usefulness has led to interdisciplinary approaches com-
bining the two: family-centered CATs. Studies on such interdisciplinary approaches are emerg-
ing in art therapy as well as dance movement therapy and are increasing in number,
particularly in the field of music therapy.
A burgeoning body of literature includes reports of positive outcomes. Examples of these in
music therapy include children with autism gaining social skills (Allgood, 2005; Hernandez-
Ruiz, 2018; Thompson et al., 2014), enhanced parent–child relationships (Allgood, 2005;
Thompson et al., 2014; Thompson & McFerran, 2015), and long-term benefits to social rela-
tionships within the family (Thompson, 2017). Recognizing the “emerging process and the scar-
city of the literature,” Hernandez-Ruiz (2021, p. 404) conducted a systematic review on parent-
mediated music interventions. Parent-mediated interventions refer to models in which the par-
ents are involved in setting goals, receive education and monitoring, and, crucially, implement
the intervention strategies for their children (Zwaigenbaum et al., 2015). A review by
Hernandez-Ruiz (2021) found that despite emerging interest in involving parents in treatment,
there were limited conceptual frameworks for parent coaching, a frequent component of par-
ent-mediated interventions, and limited development of parent-mediated music interventions.
Hernandez-Ruiz’s rationale for developing a better understanding on how to involve parents in
parent-mediated music interventions is applicable to the other CATs modalities as well, consid-
ering research showing their benefits for children with autism, including in art therapy
(Schweizer et al., 2014), drama therapy (Bololia et al., 2022), and dance movement therapy
(Takahashi et al., 2019). The research gaps she identified echo a larger gap pertaining to devel-
opment of family-centered CATs with children with autism.
Building on these important works, this review, focused on family-centered CATs,
(a) widens the lens to include all CATs modalities, in addition to music therapy, to shed light
on shared and unique features of the different modalities, and combinations of such modalities;
(b) investigates theoretical influences, in addition to CATs and family-centered components, for
a deeper understanding of the mechanisms underlying family-centered CATs; and (c) includes
all relevant family-centered studies, without a distinction between parent-mediated or parent
participation models. To elucidate, in this review, family-centered therapy is understood as both
parent and child being in the same place at the same time, led by a qualified creative arts thera-
pist, who may or may not be in the same time and space as the family. This may encompass
both parent-mediated models (in which the parent provides the interventions to the child) and
parent participation models (in which it may be the parent or the therapist providing interven-
tions). It is hoped that this review will generate new ways of thinking and working to meet the
diverse needs of families of children with autism.

AUTISM
Autism, used in this review as shorthand for autism spectrum disorder or autism spectrum con-
dition, refers to a neurodevelopmental condition arising in early childhood. It affects roughly
1% of the population (NHS Information Centre, 2012) and is characterized by atypical social
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414 FAMILY RELATIONS

skills and communication and by restricted and repetitive behaviors or interests. The term
autism spectrum is used to reflect the variation among individuals with autism, observed by
symptom type and severity. A growing movement among activist adults with autism regards it
as a neurodevelopmental difference rather than a disorder (National Autistic Society, 2020).
This idea, that differences in brain function and behavioral traits are part of normal human var-
iation, lies at the heart of neurodiversity. Such differences require understanding and appropri-
ate responses, particularly from those in the immediate environmental system of children with
autism—namely, their families.

FAMILY-CENTERED PRACTICE WITH CHILDREN WITH AUTISM

The family-centered approach refers to “a particular set of beliefs, principles, values, and prac-
tices for supporting and strengthening family capacity to enhance and promote child develop-
ment and learning” (Dunst, 2002, p. 139). Dunst et al. (2007) conducted a meta-analysis of
47 studies investigating the relationship between family-centered help-giving practices and par-
ent, family, and child behavior and functioning. Family-centered practices were associated with
improved parent self-efficacy beliefs, leading to child development.
In Coogle and Hanline’s (2014) exploratory qualitative study of family-centered practices in
early intervention services for mothers with a young child at risk of autism, links were made
between specific family-centered practices and their outcomes. Interpersonal skills of practi-
tioners and family collaboration led to positive experiences for mothers; asset-based attitudes
led to family progress and competence; supportive provider communication techniques led to
effective partnerships; and practitioner responsiveness to help families access resources and
facilitate child development led to satisfaction with early intervention practices. Recently, a sys-
tematic review on family-centered occupational therapy with children with autism (Watling
et al., 2023) found emerging evidence supporting the use of coaching interventions with care-
givers to address both parent and child outcomes. Another field that has contributed to litera-
ture on helpful practices with families of children with autism is the CATs, discussed
subsequently.

CATS FOR CHILDREN WITH AUTISM AND THEIR FAMILIES

Creative arts therapies is an umbrella term that comprises art therapy, bibliotherapy, dance
movement therapy, drama therapy, and music therapy, referring to the use of the “creative and
expressive process of art making to improve and enhance the psychological and social wellbeing
of individuals of all ages and health conditions” (Shafir et al., 2020, p. 1). A survey of the litera-
ture reveals positive outcomes associated with the various CAT modalities.
A systematic review by Geretsegger et al. (2014) on music therapy for individuals with
autism indicates that music therapy may help children with autism improve their skills in social
interaction, verbal communication, initiating behavior, and social–emotional reciprocity; may
help enhance nonverbal communication skills within the therapy context; and may contribute
to increased social adaptation skills and improve the quality of parent–child relationships. Simi-
larly, a review for dance movement therapy was conducted by Takahashi et al. (2019).
Although noting the need for more evidence-based studies, they reported that dance movement
therapy can enable social improvements in children and adolescents with autism; specifically,
mirroring interventions are helpful in this regard. A systematic integrative review on
dramatherapy for children and adolescents with autism (Bololia et al., 2022) reported methodo-
logical limitations but also benefits, including enhanced social competence, interaction and con-
versation skills, and emotional development as well as decreases in maladaptive behavior.
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FAMILY-CENTERED CREATIVE ARTS THERAPIES AND AUTISM 415

Likewise, in a systematic review (Schweizer et al., 2014) in art therapy with children with
autism, the authors recommended research to improve the evidence base while reporting that
art therapy may contribute to a more flexible and relaxed attitude, better self-image, and
improved communicative and learning skills. Notably, there seems to be no research on biblio-
therapy with children with autism. Following their survey on the use of bibliotherapy in the
United States, Abraham et al. (2020) concluded that further research is needed to gain a better
understanding of bibliotherapy as a potential resource for children with autism.
Although each CAT modality may have unique techniques and approaches, there are sev-
eral shared mechanisms of change, some of which are particularly relevant for children with
autism and their families. Given the social communication atypicality of individuals
with autism and possible co-occurring learning disabilities, traditional verbal methods of com-
munication and engagement may be challenging. As such, the CATs can be empowering by
facilitating embodied experiences and nonverbal expression to process and express thoughts,
feelings, sensations, and perceptions. Previous studies have explained the integral role of
embodiment and motility in therapeutic interaction and intervention with individuals with
autism (e.g., Vulcan, 2021). Through artistic expression, the CATs can “engage individuals on
multiple levels” (e.g., Van Lith & Ettenberger, 2023, p. 351), highlighting their inherently
strengths-based approach.
Another key defining feature of the CATs is its focus on relationships. Be it between client
and therapist or clients in a group, relationships are seen as “a dynamic and vital force for
growth and change” in the CATs (Shafir et al., 2020, p. 1). Social differences are a key feature
of autism, often impacting their relationships, and families frequently represent the most imme-
diate relationships of children with autism. This underscores the need to focus on family rela-
tionships, the family’s potential for effecting change, and the role that the CATs can play.

THE SCOPE OF THIS SYSTEMATIC REVIEW

This systematic review aims to understand in depth why family-centered CATs are done and
how. In contrast to an aggregative review, this configurative systematic review aims to “inter-
pret and understand the world” by interpreting and arranging information and developing con-
cepts (Gough et al., 2012, p. 3). This entails configuring information on each study’s theoretical
influences, CATs components, and family-centered components. A large proportion of the sea-
rch results are from music therapy; therefore, this review does not focus on efficacy or outcomes
because the results may not be meaningfully representative of the CATs. Instead, it is hoped
that this review will shed light on the mechanisms of family-centered CATs for children with
autism to generate new ways of understanding and working.

METHODS

Selection process
The following electronic databases were searched between November 14, 2023, and December
5, 2023. These include ProQuest (a collection of 54 databases including ones such as PsycINFO,
MEDLINE, and ERIC), Social Sciences Citation Index, Scopus, CINAHL, Embase, Cochrane
Library, and PROSPERO. The search strategy targeted results from primary and secondary lit-
erature, but only primary literature in the form of peer-reviewed articles from scholarly journals
were included in this systematic review (although secondary literature, such as reviews, served
as reference). There was no restriction on the year of publication.
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416 FAMILY RELATIONS

The titles and abstracts of studies were searched, using a string of terms encompassing the
key aspects of creative arts therapies (CATs), autism, and family. These strings were namely
“art OR dance OR (dance AND movement) OR drama OR psychodrama OR music OR
poetry OR biblio”; combined with “*therapy”; combined with “autis*” OR asperger* OR (per-
vasive AND developmental AND disorder) OR (childhood AND disintegrative AND disor-
der)”; combined with “famil* OR parent OR mother OR father.”
The results were then screened for duplicates, and then further screened for their eligibility
based on a close reading of their abstracts, and then a full reading of the texts. This procedure
was done using the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) Flow Diagram as a guide, as seen in Supplemental Figure 1. A total of 612 records
were identified through database search, and an additional three were hand-searched from
other sources. After duplicate results were removed, 370 records were screened—first on the
basis of their titles and abstracts, and then the remaining 53 full-text articles were assessed for
their eligibility based on the inclusion and exclusion criteria determined for this study.

Inclusion and exclusion criteria

Studies that met the following criteria were included. First, peer-reviewed articles from schol-
arly journals; articles written in English, and articles written in another language but that
offered English translations were included. Second, studies based on children and adolescents,
from age 2 years to less than 18 years, with a diagnosis of autism, including those falling under
the categories of Asperger syndrome and pervasive developmental disorder—not otherwise
specified; and studies with most participants (75% or more) meeting these inclusion criteria were
included. Third, there were no restrictions on the settings of the interventions. They could be
conducted in venues such as schools or the homes of the families involved. Fourth, only inter-
ventions designed or conducted by qualified creative arts therapists held with the intention of
providing therapy to clients according to the definition of each of the CATs were included. For
this review, family-centered therapies include those involving parents or siblings and children at
the same time and space together, as facilitated by a therapist, who may or may not be in the
same space and time as the family.
Studies that met the following criteria were excluded. First, theoretical studies, opinion
pieces, abstracts presented in conferences, letters to editors, brief reports, and unpublished the-
ses were excluded. Second, studies with children and adolescents with learning disabilities or
developmental delays but who were not mentioned as having autism were excluded. Third, arts
activities or practices that did not meet the definition of any of the CATs; studies involving cre-
ative arts therapists that featured elements or methods of therapy but were not embedded within
whole sessions of therapy; and studies solely relating to expressive arts therapies (a multimodal
approach, distinct from the CATs) were excluded. Adhering to these criteria resulted in the
inclusion of 17 studies.

Quality assessment

The selected studies were assessed for their quality using the assessment tools developed by
Oxford Centre for Evidence-Based Medicine (2009)—namely, Levels of Evidence (LOE), devel-
oped to help offer clinical advice in the face of flawed evidence by advising the reader of such
flaws. It does so through a rating scaled comprising 10 levels, ranging from 1a to 5, with 1a
being the highest and 5 being the lowest rated type of evidence.
Supplemental Table 1 details the LOE template and the categories of the studies selected for
this review. Only one study was a Level 1b: randomized controlled trial (Thompson
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FAMILY-CENTERED CREATIVE ARTS THERAPIES AND AUTISM 417

et al., 2014), whereas two others were Level 3b: Individual Case–Control Studies (Ravarian
et al., 2017; Ren et al., 2022). The remaining studies were Level 4: Case Series (and Poor Qual-
ity Cohort and Case–Control Studies).

Data extraction
A deductive approach to thematic analysis (Braun & Clarke, 2022) was applied as the aim was
to gain a better understanding of the mechanisms of family-centered CATs, and it made sense
to consider theoretical influences, CATs components, and family-centered components. Any
uncertainties were addressed by emailing the correspondence author of the study. Both semantic
and latent approaches (Braun & Clarke, 2022) helped in analyzing the texts.
Because the theoretical influences were not always readily apparent, each paper was combed
through three times to locate any text relating to theoretical influences. All related quotes were
then extracted verbatim. Each quote was then assigned a label, following discussion between
the authors of this review. Where the authors of the papers did not state their theoretical influ-
ences explicitly, assigning labels entailed interpreting the quotes to understand possible theoreti-
cal underpinnings.

Data synthesis
The information gathered was then analyzed using the procedures of thematic analysis (Braun &
Clarke, 2022). Supplemental Table 2 demonstrates how coding led to a subtheme and then a
larger theme.

Trustworthiness of qualitative data

To ensure trustworthiness of the final data set, credibility, dependability, and confirmability
were considered. To maintain credibility, the second author checked the coding and analyses of
the first author to reach a consensus. To ensure dependability, rigorous techniques were used to
gather the data, in accordance with the PRISMA guidelines, which facilitate transparency in
systematic reviews. To improve confirmability, an audit of the data was conducted by a
researcher external to the project, who was experienced with qualitative research and systematic
reviews.

RESULTS
Characteristics of studies
Table 1 lists the characteristics of the 17 studies included in this systematic review. In terms of
the CAT modalities, most of the studies were related to music therapy (77%, n = 12). Also rep-
resented were art therapy (6%, n = 1) and dance movement therapy (6%, n = 1). Another study
was based on a mix of music and movement therapy, and Bitan and Regev’s (2022)
study encompassed the experiences of 10 music therapists, 10 art therapists, and five dance
movement therapists. Format-wise, most studies were based on individual family-centered ther-
apy, meaning one family was involved in therapy at a time (71%, n = 12). Some studies
employed the group family-centered therapy approach, meaning several families were involved
in therapy together (24%, n = 4). It was unclear which format was employed in one study
(6%, n = 1).
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418 FAMILY RELATIONS

TABLE 1 Characteristics of studies.

No. of
Study characteristics Studiesa studies

CAT modality
Art therapy 11 1
Dance movement therapy 10 1
Mixed: music and movement therapy 12 1
Music therapy 1, 2, 4, 5, 6, 7, 8, 9, 13, 14, 15, 16, 17 13
Variety: art, dance movement, and music therapy 3 1
Therapy format
Individual (one family in therapy at a time) 3, 4, 5, 6, 7, 8, 9, 13, 14, 15, 16, 17 12
Group (two or more families in therapy at a time) 1, 5, 10 3
Unclear 12 1
Setting of therapy
In person 1, 2, 3, 4, 5, 7, 8, 9, 11, 13, 14, 15, 16, 17 14
Assessment and treatment center attached to a 9 1
hospital
Community center 8 1
Home 2,12, 13, 14, 15, 16 6
Music therapy clinic 5 1
Music therapy rooms of universities 4, 17 2
School for autism 1, 11 2
Treatment center 3 1
b
Mixed 12 1
Virtual (Zoom) with families at home 6, 10 2
Frequency of therapy
Biweekly 3, 4, 5 3
Weekly 1, 2, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 14
Duration of each therapy session, minutes
< 30 15 1
30–60 1, 2, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 15
17
Unclear 3,11 2
Duration of the entire therapy program
1–4 months 1, 4, 5, 6, 7, 10, 12, 13, 14, 15, 16, 17 12
4 months–1 year — 0
>1 year 2, 8, 9 3
Unclear 3, 11 2
Participants of the study
Children with formal diagnoses of autism Every study 17
2.5–6 years old 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 13, 14, 15, 16, 17 15
7–10 years old 1, 8 2
10–18 years old 8 1
Age unclear 11, 12 2
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FAMILY-CENTERED CREATIVE ARTS THERAPIES AND AUTISM 419

TABLE 1 (Continued)
No. of
Study characteristics Studiesa studies

Siblings 1, 2, 5, 9, 13 5
Parents of children with autism Every study 17
Therapists 3 1
Continents and countries
Asia (China, Iran, Israel, Japan, Thailand) 3, 4, 8, 11, 12 5
Australasia (Australia, New Zealand) 2, 13, 14, 15, 16 5
North America (Mexico, United States) 1, 5, 6, 7 4
Europe (United Kingdom, Cyprus) 9, 10, 17 3
Note. CAT = creative arts therapy.
a
The numbers denote the following studies: 1. Allgood, 2005; 2. Ayson, 2011; 3. Bitan & Regev, 2022; 4. Chanyanit et al., 2019; 5.
Hernandez-Ruiz, 2017; 6. Hernandez-Ruiz, 2023; 7. Hernandez-Ruiz & Braden, 2021; 8. Ishihara, 2017; 9. Loombe, 2017; 10. Moo &
Ho, 2023; 11. Ravarian et al., 2017; 12. Ren et al., 2022; 13. Thompson, 2014; 14. Thompson et al., 2014; 15. Thompson &
McFerran, 2015; 16. Thompson, 2017; 17. Vaiouli & Andreu, 2022.
b
Children received therapy at home, and parents participated in online training.

In most studies, therapy was held in person, face-to-face (82%, n = 14). In a few cases, ther-
apy was held virtually using Zoom video conferencing (12%, n = 2), or where children received
therapy at home while their parents participated in online training (6%, n = 1). The settings for
therapy varied, but family homes were the most common (47%, n = 8), followed by schools
(12%, n = 2), music therapy clinics (12%, n = 2), and the music therapy rooms of universities
(12%, n = 2). Other settings included an assessment and treatment center attached to a hospital,
a community center, and a treatment center, each mentioned once. Contexts of the larger set-
ting varied as well, with most studies conducted in Asia (29%, n = 5) and Australasia (29%,
n = 5), followed closely by North America (24%, n = 4), and Europe (18%, n = 3).
As for the frequency of interventions, most studies ran their interventions weekly (82%,
n = 14), except for a few studies in which therapy was provided biweekly (18%, n = 3). Regard-
ing program duration, 1 to 4 months was the norm (71%, n = 12). In a few studies, the duration
was longer than a year (18%, n = 3), and in certain studies, the duration was clear (12%). How-
ever, this ranged considerably, when considering different formats. Group family-centered ther-
apy ranged from 6 to 15 weeks, whereas individual family-centered therapy ranged from
6 weeks to 13 years. There seemed to be more homogeneity in terms of the duration of each ses-
sion, with 30 to 60 minutes being the norm (88%, n = 15). This duration was unclear in certain
studies (12%, n = 2).
In terms of the participants, all the children had formal diagnoses of autism. In all studies,
the children were between 2.5 to 6 years old when they started therapy. However, in two stud-
ies, therapy continued until the child was 7 to 10 years old (12%, n = 2) in one and between
10 to 18 years old (6%, n = 1) in another. It was unclear in certain studies how old the children
were (12%, n = 2). With regard to family members, all the studies mentioned a parent or both
taking part, and several also mentioned sibling participation (29%, n = 5).

Findings: Themes and subthemes

Analyses of the studies revealed subthemes leading to larger themes pertaining to theoretical
influences, CAT components, and family-centered components. These are listed in Table 2,
which also shows the supporting studies.
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420 FAMILY RELATIONS

TABLE 2 Theoretical influences, creative arts therapies components, and family-centered components: Themes and
subthemes.

No. of
Themes Subthemes Studiesa studies

Theoretical influences
Developmental psychology Attachment (Bowlby, 1951; Ainsworth, 1963) 4, 15 2
Ecological (Bronfenbrenner, 1999) 1, 2, 3, 13, 14, 8
15, 16, 17
Interpersonal (Stack-Sullivan, 1953) 3, 13, 14, 15, 6
16, 17
Intersubjectivity (Stern, 1985) 9, 13, 14, 15, 5
16
Sociocultural (Vygotsky, 1978) 5, 6, 7, 10, 13, 9
14, 15, 16, 17
Humanistic psychology Positive regard and self-worth (Rogers, 1951) 2, 9, 12, 13, 6
15, 16
Self-efficacy (Bandura, 1977) 3, 5, 6, 7, 9, 7
10, 13
Psychodynamics Analytical psychology (Jung, 1953) 3 1
Holding (Winnicott, 1971) 9, 10 2
Object relations (Winnicott, 1960, 1963) 8 1
Transactional analysis (Berne, 1958) 12 1
Behavioral psychology Operant conditioning (Skinner, 1948) 5, 6, 7, 17 1
Arts-centered Art as therapy (Kramer,1971) 3, 11 1
Communicative musicality (Malloch & 4 4
Trevarthen, 2009)
Philosophical Embodied cognition (Merleau-Ponty, 1962) 10, 12 2
Neurobehavioral Mirror neuron system (Dapretto et al., 2006; 10 1
Gallese, 2005)
Neurological perspectives of music 6 2
Creative arts therapy components
Common therapy practices Assessment Every study 17
Reflexivityb 3 1
Understanding the sensory profile of the child 3 1
c
Ways of engaging Attuning and mirroring 3, 7, 10, 13, 6
15, 16
Being directive 4, 5, 10, 11, 12 5
Consistency and structured sessions 1, 5, 8, 9, 10, 6
14
Games and playing 2, 5, 9, 10, 17 5
Improvisation (referring to the spontaneous and 1, 5, 7, 8, 9, 8
unscripted use of artistic expression as a therapeutic 10, 13, 16
tool)
Working in a different modality to one’s own if a child 3 1
might relate to it more
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FAMILY-CENTERED CREATIVE ARTS THERAPIES AND AUTISM 421

TABLE 2 (Continued)
No. of
Themes Subthemes Studiesa studies

Family centered
Collaborating Setting goals together 1, 2, 3, 8, 9 5
Sharing knowledge to optimize child engagement 10, 13 2
Mutual therapist–parent learning to understand the 3 1
child
Guiding and supporting Facilitating therapeutic experiences for the parents 10 1
parents to interact with their without their children
children
Modeling behaviors and strategies 3, 4, 5, 9, 12, 7
13, 15
Preparatory meetings with parents 1, 4, 6, 10, 17 5
Providing materials (e.g., video recordings or manuals) 12, 17 2
Offering verbal support by coaching, discussing, and 2, 4, 5, 6, 9, 8
encouraging 10, 11, 17
Reflections with parents after sessions 2, 4, 10 3
Providing opportunities for Understanding the needs of the dyad 3 1
interaction
Through creative arts-based contexts Every study 17
a
Note. Numbers denote the studies as follows: 1. Allgood, 2005; 2. Ayson, 2011; 3. Bitan & Regev, 2022; 4. Chanyanit et al., 2019; 5.
Hernandez-Ruiz, 2017; 6. Hernandez-Ruiz, 2023; 7. Hernandez-Ruiz & Braden, 2021; 8. Ishihara, 2017; 9. Loombe, 2017; 10. Moo &
Ho, 2023; 11. Ravarian et al., 2017; 12. Ren et al., 2022; 13. Thompson, 2014; 14. Thompson et al., 2014; 15. Thompson &
McFerran, 2015; 16. Thompson, 2017; 17. Vaiouli & Andreu, 2022.
b
Reflexivity refers to the therapist’s ongoing process of self-awareness; critical reflection; and examination of their beliefs, values, biases,
and assumptions in relation to their work with their clients.
c
Attuning refers to the therapist connecting to the client’s creative expression, emotional communication, and inner world through arts-
based mediums, and mirroring refers to the therapists’ reflecting the client’s expressions or movements, often through similar or
complementary artistic or movement-based responses.

Theoretical influences
Several studies drew purely from one school of thought, whereas others drew from a variety of
theoretical influences. Analyses led to seven themes based on schools of thought: developmental
psychology, humanistic psychology, psychodynamics, behavioral psychology, arts-centered
theories, philosophical theories, and neurological perspectives. Findings revealed that develop-
mental psychology underpinned most studies (82%, n = 14). In particular, the development-in-
context perspective was apparent in many studies, referring to Vygotsky’s (1978) sociocultural
theory (53%, n = 9) and Bronfenbrenner’s (1999) ecological theory (47%, n = 8). Several other
theories from developmental psychology were seen, including interpersonal theory (Stack-Sulli-
van, 1953; 35%, n = 6); intersubjectivity (Stern, 1985; 29%, n = 5); and attachment theory
(Ainsworth, 1963; Bowlby, 1951; 12%, n = 2). The next most salient theoretical influence came
from humanistic psychology (65%, n = 11). A sizeable number of studies drew from Bandura’s
(1977) self-efficacy theory (41%, n = 7) and Rogers’s (1951) positive regard and self-worth
(35%, n = 6).
Theoretical influences from psychodynamics were seen as well, including Winnicott’s (1971)
holding (12%, n = 2). Meanwhile, Jung’s (1953) analytical psychology, Winnicott’s (1960,
1963) object relations, and Berne’s (1958) transactional analysis were each mentioned in one
study (6%, n = 1). Behavioral psychology was an influence as well, with several studies drawing
on Skinner’s (1948) operant conditioning (24%, n = 4). Unlike the other schools of thought,
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422 FAMILY RELATIONS

which each informed at least two CATs modalities, behavioral psychology was only used in
music therapy.
In addition, there were theoretical influences from outside of the field of psychology, includ-
ing arts-centered, philosophical, and neurobehavioral theories. This included Kramer’s (1971)
art as therapy (12%, n = 2); Merleau-Ponty’s (1962) embodied cognition (12%, n = 2); the mir-
ror neuron system, which has been researched by various scientists (e.g., Dapretto et al., 2006;
Gallese, 2005; 6%, n = 1); and neurological perspectives of music (6%, n = 1).

CATs components

Analyses revealed that CATs components can be grouped into three major themes: creative arts
elements, common therapy practices, and ways of engaging. With regard to creative arts ele-
ments, music and singing was the most frequently mentioned subtheme (76%, n = 13), followed
by body movement and physical action (71%, n = 12). The use of artmaking and art materials
was also seen, although less commonly (12%, n = 2).
As for common therapy practices, assessment was undertaken in every study. Reflexivity
was mentioned in one study (6%, n = 1), referring to the therapist’s ongoing process of self-
awareness; critical reflection; and examination of their beliefs, values, biases, and assumptions,
in relation to their work with their clients. Also, understanding the sensory profile of the child
was mentioned (6%, n = 1).
In terms of ways of engaging, the most mentioned method was improvisation, referring to
the spontaneous and unscripted use of artistic expression as a therapeutic tool (47%, n = 8).
This was followed closely by attuning and mirroring (35%, n = 6). Attuning refers to the thera-
pist connecting to the client’s creative expression, emotional communication, and inner world
through arts-based mediums, and mirroring refers to the therapist reflecting the client’s expres-
sions or movements, often through similar or complementary artistic or movement-based
responses. Providing consistency and structured sessions were an equally prominent method
(35%, n = 6). Other methods included being directive (29%, n = 5), games and playing (29%,
n = 5), and working in a different modality to one’s own if the child might relate to it more
(6%, n = 1).

Family-centered components

Analyses revealed that family-centered components could be grouped into subthemes leading to
three major themes: collaborating, guiding and supporting parents to interact with their chil-
dren, and promoting opportunities for parent–child interaction. Collaboration was prominently
seen in the context of setting goals together with the parents (29%, n = 5). Other methods of col-
laboration include sharing knowledge to optimize child engagement (12%, n = 2) and mutual
therapist–parent learning to understand the child (6%, n = 1).
In terms of guiding and supporting parents to interact with their children, the most rec-
urringly mentioned method was offering verbal support by coaching, discussing, and encourag-
ing (47%, n = 8) as well as modeling behaviors and strategies (41%, n = 7). Other methods
included preparatory meetings with parents (29%, n = 5), reflection with the parents after ses-
sions (18%, n = 3), providing materials (e.g., video recordings or manuals; 12%, n = 2), and
facilitating therapeutic experiences for the parents without their children (6%, n = 1). Lastly,
with regard to providing opportunities for parent–child interaction, every study accomplished
this through creative arts–based contexts, whereas understanding the needs of the dyad was
mentioned in one study (6%, n = 1).
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FAMILY-CENTERED CREATIVE ARTS THERAPIES AND AUTISM 423

DISCUSSION

This systematic review investigated family-centered CATs for children with autism to gain a
better understanding of why and how they are done. Briefly, the findings revealed the impor-
tance of the development-in-context perspective as a theoretical influence; music and body
movement as CATs components; and verbal support as well as modeling behaviors and strate-
gies to parents as family-centered components. It also highlighted the varying stages of develop-
ment of family-centered work across the various CATs modalities.
Although there is emerging literature on family-centered art therapy (Bitan & Regev, 2022;
Ravarian et al., 2017) and family-centered dance movement therapy (Bitan &
Regev, 2022; Moo & Ho, 2023), at the time of this writing, there were no scholarly articles on
family-centered drama therapy for children with autism or family-centered bibliotherapy. Each
CAT modality (except for bibliotherapy, in which there is no research to date) has been shown
to bring unique benefits when working with children with autism, as documented in the reviews
by Schweizer (2014) for art therapy, Takahashi et al. (2019) for dance movement therapy,
Bololia (2022) for drama therapy, and Geretsegger (2014) for music therapy. As such, the dis-
crepancies found in this systematic review warrant a closer look.
Reflecting on the commonalities shared by the modalities represented in this systematic
review may shed light on which mechanisms of change are accessible or helpful to children with
autism and their families. While noting that dramatherapy often uses body movement and
physical action, the modalities of art, dance movement, and music therapy may be different
from drama and bibliotherapy because they combine several elements. First, art, dance move-
ment, and music therapy are primarily based on nonverbal languages of communication—art,
movement, and music. This may be helpful for children with autism, who may struggle with tra-
ditional verbal methods of communication, as highlighted in previous studies (e.g., Van Lith &
Ettenberger, 2023). On the basis of their study drawing on art, dance movement, and music
therapy, Bitan and Regev (2022) explained that CATs enable children with autism to express
themselves and convey their experiences “in a non-threatening way” (p. 6) because they do not
require words. Second, the actions and interactions in these three modalities often produce con-
crete changes in the environment or in the body that can be perceived by the senses. This may
represent a meaningful form of engagement for children with autism who may be motivated
sensorily or for whom symbolism and abstract thought may be less natural. Tellingly, Temple
Grandin (2009), a professor, animal behaviorist, and autism self-advocate, related the
following:

Since my mind stores information as photo-realistic pictures, I do not have true

abstract thinking. To visualize the concept of my future after high school, I had to
use door symbols. In fact, the first door symbols were real doors I could practice
walking through. (p. 1438)

Third, these three modalities can facilitate embodiment, referring to the unity of mind and
body, a foundational element in therapy with individuals with autism that has been mentioned
in previous studies (e.g., Vulcan, 2021). This can potentially provide avenues for the child with
autism to process and express their thoughts, feelings, sensations, and perceptions; self-regulate;
and relate. In sum, the nonverbal, sensorial, and embodied aspects that come together in these
CATs modalities may be valuable in working with families of children with autism.
This systematic review focused on theoretical influences, CATs components, and family-
centered components. Theoretical influences from developmental psychology were seen across
the modalities, especially the development-in-context perspective, espoused by Vygotsky (1978)
and Bronfenbrenner (1999). According to Vygotsky (1978), children develop cognitively
through social interactions. Bronfenbrenner (1999) emphasized the importance of
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424 FAMILY RELATIONS

environmental factors and social influences in shaping human development. Together, they
underscore the integral role of the parent–child relationship in the child’s development. In the
context of this review, this highlights how the range of CATs may be valuable in how they can
offer different modes for parents to relate with their neurodiverse children. This simple but new
finding has implications for practice and research.
In terms of CATs components, this review found that the creative arts elements were a dom-
inant theme. Besides music and singing, body movement and physical activity are commonly
cited, even within family-centered music therapy—for example, movement to music, folk
dances (Allgood, 2005); acting out action songs, jumping in time to music, bouncing on a bed
(Ayson, 2011); action songs, physical interaction with parents (e.g., hugging, dancing, and rid-
ing on a parent’s back; Chanyanit et al., 2019). This potentially points to the importance of
body movement in family-centered therapy with children with autism and aligns with previous
research. Srinivasan and Bhat (2013) called for embodied interventions incorporating music
and movement for multisystem development in children with autism. More recently, Vulcan
(2021) conducted a qualitative study on the experiences of a range of therapists (a variety of cre-
ative arts therapists, clinical psychologists, and clinical social workers) working with individuals
with autism. Across the different professional orientations and practices, “the primacy and
foundational role of the concrete body in intersubjective relationships and in the therapeutic
process” (p. 1) was evident. The author advocated training therapists working with clients with
autism to develop the “muscles of the psyche” (p. 10) for improved understanding of the inner
emotional states of clients.
Body movement in therapy is indeed the prime focus of practice and research in dance
movement therapy. However, existing literature in dance movement therapy has focused mainly
either on children with autism (e.g., Fan & Ko, 2023; Scharoun et al., 2014) or their parents (e.
g., Aithal et al., 2023; Champagne & MacDonald, 2022). Only recently was one study con-
ducted that explored dance movement therapy for parents and their children with autism
together (Moo & Ho, 2023). Despite the challenges inherent to this study because it was a tele–
dance movement therapy program conducted through video conferencing during the coronavi-
rus pandemic, the parents reported positive outcomes. These included the child’s social develop-
ment, enjoyment, improved understanding of their child, insight and ideas, and relationship
building, illustrating the benefits of using body movement in family-centered work with autism.
In terms of family-centered components, the most mentioned was guiding and supporting
parents to interact with their children, often done by offering verbal support and by modelling
behaviors and strategies to parents. Modeling was done in person in all the studies in this review
except for one (Ren et al., 2022), in which prerecorded material was used. The prevalence of
modeling in person might be linked to the relational thrust of the CATs. It may be sufficient to
offer verbal support and to provide training materials such as video recordings or manuals in
contexts where there is a more “straightforward” transmission of knowledge from the therapist
to the parent to the child—for example, in a study by Aqdassi et al. (2021) on family-based
occupational therapy program for children with autism. However, where the focus of the work
is relational, modeling behaviors or strategies to parents by working directly with the child may
be advantageous. In doing so, the therapist may be better positioned to experience the child
intersubjectively, empathize with the child and parent, and formulate appropriate strategies
unique to them. In Bitan and Regev’s (2022) study, most creative arts therapists mentioned how
modeling can help the child with autism be “more completely understood, contained, and
secure” (p. 13). The parent, in turn, by witnessing alternative ways of relating to the child, may
be freed to try these themselves and gain greater insight into their relationship dynamics by
being an observer. These speculations may explain the findings of this review.
Lastly, in the context of promoting parent–child interaction, “understanding the needs of
the dyad” was explicitly mentioned in only one of the studies (Bitan & Regev, 2022) in this
review. Although creative arts elements such as art, movement, and music can provide cross-
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FAMILY-CENTERED CREATIVE ARTS THERAPIES AND AUTISM 425

cultural, “universal” means of understanding others, specific influences, such as cultural aspects,
are always present. Ravindran and Myers (2012) expounded on several cultural influences rele-
vant to autism: parents’ beliefs about the causes of their child’s “disability” and how this affects
the treatments they seek for their child and their expectations regarding outcomes; cultural fac-
tors influencing the resources available to children with disabilities; who families rely on for
support; and the relationships between parents and the professionals providing interventions
for their children. In family-centered therapy with children with autism, it would seem pertinent
to understand the needs of the dyad by considering their culture, but this was not frequently
mentioned in the studies in this review, perhaps because of the studies’ focus on the “universal”
elements driving CATs.

Limitations

This systematic review has several limitations that may have influenced its findings. First, only
peer-reviewed articles from scholarly journals were included to maintain a level of scientific
rigor. Book chapters that may have been insightful were excluded, possibly limiting the scope
of research that could be drawn upon. To manage readers’ expectations, this exclusion was
mentioned explicitly as an exclusion criterion. Second, the implications drawn were limited by
the lens of the authors, who are both dance movement therapists with a natural focus on body
movement as a mechanism of change. Other relevant implications may have been missed.
Although the authors conducted research on the other CATs for a wider viewpoint, future
research by creative arts therapists from other modalities would enrich the development of this
field.

Implications
The findings of this systematic review bear implications for practice and research. They may be
of benefit to families with children with autism; therapists; Certified Family Life Educators
(CFLEs), particularly in relation to the internal dynamics of families; and other professionals
working with children with autism.
First, the distinguishing features characterizing the CAT modalities represented in this
review (art, dance movement, and music therapy) bear implications. They can be employed to
stimulate services that are currently nonexistent or undocumented in the context of children
with autism (e.g., bibliotherapy). To start, bibliotherapists facilitating shared reading activities
between parents and their child with autism may wish to improve engagement by tapping into
nonverbal, sensorial, and embodied experiences. This can be done for instance, by using devel-
opmentally appropriate picture books and facilitating creative movement or acting out of the
feelings, characters, scenes, and storylines. Meanwhile, CFLEs may wish to disseminate infor-
mation and advice (Doherty & Lamson, 2015) on the importance of engaging children with
autism using nonverbal, sensorial, and embodied experiences. For instance, simple activities
such as cooking together may be a starting point for families. In Doherty and Lamson’s (2015)
levels of family involvement (LFI) model, dissemination of information (LFI Level 1) is meant
to be collaborative. CFLEs could work together with the families of children with autism to
determine their child’s own interests as a starting point in this.
Second, the importance of the development-in-context perspective in different CATs has
several implications. The application of this perspective can lead to more focused interventions
in emerging therapies, such as family-centered art therapy for children with autism. For
instance, Schweizer (2014) emphasized the experiential nature of art therapy and how tactile
and visual experience can stimulate behavioral change in children with autism. It may be worth
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426 FAMILY RELATIONS

investigating, for example, how parents can promote and share in sensory artmaking experi-
ences for their children with autism. CFLEs can support families to interact socially with their
children with autism by providing resources and connections (Doherty & Lamson, 2015) to help
them in this—for example, by referring them to family-centered CATs—to help maximize con-
tinuity of care (LFI Level 4).
Third, the prominence of body movement and physical activity in relating to children with
autism bears implications. Their widespread use as a therapeutic element, even in music ther-
apy, behooves dance movement therapists to apply their expertise in movement in family-cen-
tered work with children with autism (e.g., Moo & Ho, 2023). Given the sociocommunicative
difficulty in autism, families of children with autism might, for example, benefit from bolstered
kinesthetic empathy, referring to a deeper understanding of another person by experiencing
their movement and reflecting on how it feels within one’s own body (Behrends et al., 2016;
Fischman, 2009). Enhanced body awareness and body language can then be easily embedded
within families’ daily routines in natural environments such as the home, a key goal in family-
centered practice because this optimizes children’s learning and engagement (Roper &
Dunst, 2003). As mentioned by the dance movement therapists in one of the studies included in
this review (Bitan & Regev, 2022), movement is always present. Body movement may be crucial
in relating to children with autism, and as such, CFLE program leaders may wish to incorpo-
rate some form of training in their programs to allow those working in this field to develop
body literacy, as Vulcan (2021) advocated, to understand and respond better to children with
autism.
Fourth, therapists’ modeling of behaviors and strategies in person may be beneficial in work
pertaining to the parent–child relationship (e.g., in family therapy) and should be a consider-
ation in the development of parent-mediated interventions. This may also be applicable to skill
building (Doherty & Lamson, 2015) undertaken by CFLEs and other professionals working
with families of children with autism. Given the significance of intersubjective relations in
autism, modeling behaviors in person may be an important skill when working to improve fam-
ily members’ feelings and need for support (LFI Level 3).
Fifth, both general and specific influences such as cultural factors, should be considered in
family-centered work. For instance, improvisation is commonly used in the CATs to facilitate
engagement, as found in this review, but certain cultures may be less open to it, for example,
cultures that are hierarchical, collectivist, or avoidant of uncertainty. Recognizing and
addressing cultural influences may improve the effectiveness of family-centered CATs. Bearing
in mind the array of cultural factors that may be present when working with families with chil-
dren with autism, CFLEs and other professionals may wish to consider collaborative assess-
ment and goal setting (Doherty & Lamson, 2015) that considers these factors. Also, families
can be helped to use their cultural resources to address a problem (LFI Level 4).

Conclusion

The main findings of this systematic review on family-centered CATs with children with autism
highlight the development-in-context perspective as a key theoretical underpinning, the ubiquity
of body movement and physical action as a therapeutic element, and the relevance of modeling
behaviors and strategies in person in family-centered practice. Additionally, this review
describes possible mechanisms facilitating engagement across modalities—activities allowing
nonverbal, sensorial, and embodied experiences were important. It is hoped that these findings
will inspire practice and research in therapy and Family Life Education to better meet the
diverse needs of families of children with autism.
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FAMILY-CENTERED CREATIVE ARTS THERAPIES AND AUTISM 427

ORCID
Janet Tein Ni Moo https://orcid.org/0000-0002-0537-2351
Rainbow Tin Hung Ho https://orcid.org/0000-0002-6173-621X

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SU P PO RT I NG I NF O RM AT IO N
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How to cite this article: Moo, J. T. N., & Ho, R. T. H. (2025). Family-centered creative
arts therapies for children with autism: A configurative systematic review. Family
Relations, 74(1), 412–429. https://doi.org/10.1111/fare.13092