In any given year, 1 in 68 Americans are diagnosed as having autism spectrum disorder (ASD), according to the Centers for Disease Control and Prevention. Many of these are young children who will face a lifetime of trying to acclimate to a world that will often seem hostile, if not dangerous and frightening. As the prevalence, awareness and diagnosis of autism have grown over the past 20 years, the design of new models for treatment has not kept pace. As healthcare designers, we believe that new and innovative architectural facility designs can significantly enhance the quality of treatment if these facilities are designed with the advance knowledge of how specific environmental factors affect the behavior and well-being of persons with ASD.
Looking for precedents is not terribly helpful since there are a limited number of purpose-built facilities for clinical diagnosis, evaluation and treatment for children with autism. However, using the latest technologies, construction methodologies and sustainable materials, it is possible to design respectful, flexible and soothing spaces, and to balance safety and regulatory concerns with the creation of therapeutic environments, which can include accommodations for families and caregivers in the treatment process.
Autism is most often accompanied by challenges in traditional social interactions, attention disorders and physical health issues—all factors that must all be taken into consideration when designing a treatment facility. In designing for patients with ASD, we should aim to make the environment as homelike, comforting and non-institutional as possible. It is important to create a feeling of ease in each space the individual moves through and to eliminate negative environmental factors.
People diagnosed as being on the autism spectrum are often highly sensitive to their environment. They are sensitive to sound, noise, light, heat and cold, and abrupt changes in their physical environments. Sound and noise can have especially negative, distracting and potentially traumatic effects. This can present some interesting design challenges, but starting with the premise that sound and noise are two different things—sound is what we hear, while noise is unwanted or disturbing sound—will ensure a better end result. To reduce noise, every space or room where treatment occurs should be isolated from adjacent spaces. The best way to acoustically isolate treatment and evaluation spaces from adjacent areas is with mass. While it’s not possible to put a two- foot stone wall between every room, it is possible to build non-continuous acoustical partitions using staggered steel studs and gypsum board. Space works nearly as well as mass, and noise can be reduced further by packing double-studded walls with sound-absorbing insulation. Using double glazing on one-way observations windows and solid core doors with continuous sound seals is also a helpful noise reducer. It is also important to make sure that all electrical outlets, all wiring, all IT and phone cables, and any HVAC ducts that pass from room to room are thoroughly sealed so there are no holes that permit transmission of sound from one space to the adjacent one.
Within individual treatment and evaluation rooms, another goal is to minimize reverberation of sound. If a patient is exhibiting challenging behavior and the room has hard ceilings, hard floors and hard walls, the room will be very alive, i.e very loud. This often can cause more agitation for the child. This then has a spiraling negative impact. Carpet is best in these instances for absorbing sound, but can be an issue from a maintenance point of view. Cushioned rubber or cork flooring is often an acceptable alternative. In addition, parallel planes reflect sound back and forth between them, amplifying the effects of noise, but by changing the angles of the walls and/or sloping the ceiling, direct echoes can be averted. Treating the ceiling with spray-on acoustical materials or using acoustical tiles will further absorb ambient noise.
All artificial lighting should be variable. In this way the inhabitant of a space has the ability to control lighting levels to whatever is most comfortable for them at the moment. Natural light should be controlled as much as possible. It’s ideal to incorporate exterior views of nature, enabling awareness of the outside and the weather. High shaded windows and angled skylights can give an ambient glow without too much direct harsh sunlight. Artificial lighting should be diffused, perhaps from hidden sources. This creates a homier feel in the space and avoids creating spaces with an over bright clinical feeling. It is also important to create some intentionally dark spaces to help mitigate a feeling of sensory overload.
Children or adolescents with autism can be agitated or distracted by overstimulation, so the use of color must not be too bold or "visually loud.” Soft, non-jarring colors (but not boring beige!) can be good in combination helping provide clarity and comfort without overwhelming a patient’s senses. Color can also be used as a way-finding tool for recognition and spatial identification. Using color coding on floors and walls allows people who "think in pictures” (like world-renowned autism spokesperson Dr. Temple Grandin) to get a sense of location, memory and spatial awareness.
The combination of color and texture creates a truly meaningful way for patients with autism to perceive their environment. There is a fine line between offering a variety of textures and overwhelming patients with opportunities to feel different surfaces. Some people with autism can be hyper-sensitive to certain textures. Spaces for children should include a range of touchable materials, so the walls have a different texture from the rubber floors, which have a different texture from the fabrics on furniture, tabletops, etc. It’s essential to use indestructible, durable materials, with an emphasis on the use of natural, sustainable materials, such as cork, rubber, wood, porcelain, wool and natural stone. Many family members, whether correctly or not, assume that artificial materials and off-gassing can contribute to the symptoms of autism.
Finally, it is critical to remove the distraction of clutter to make the space quieter and calmer by maximizing storage. Clinicians know there can never be enough storage space for items specifically used to care for children on the autism spectrum. This also gives clinicians the choice to individualize what materials to have in view for each child; these may differ considerably according to the individual child’s interests and developmental level, as well as whether the goals of a treatment of a session are to get a child to focus on particular activities or to explore the environment more broadly. Having access to adequate storage space and "display space” (such as tables within a treatment room) can mean the difference between a child feeling immediately comfortable and intrigued upon entering a room, or feeling overwhelmed or distracted, or the whole family feeling so dismal at being in a very unwelcoming space that they become even more anxious.
Observation spaces can be used to facilitate research and teaching opportunities as well as being used as a tool for teaching parents and family members how to cope with the special needs of their children and siblings. Including unobtrusive spaces for audio and video equipment is important to provide access for medical teams, and invaluable for education and training.
In the end, we must create a positive physical environment that can be a dynamic part of the treatment process. The industry still needs a scientific analysis of multiple examples of treatment facilities designed with the special needs of persons with Autism Spectrum Disorders. We need to better understand the clinical impact of design in caring for patients with ASD. As with all evidence-based design, it is always important to solicit feedback from patients, families and caregivers regarding their experience of the spaces, and to incorporate their responses in design in order to make continual improvements.
Jaques Black is a Partner with E4H Environments for Health Architecture, a nationwide architecture and design firm focused on healthcare and health innovation.