For people with autism, the world can be a complex and scary place. Recent news, films, and literature reflect the growing interest in autism, while at the same time, point to how much there is still to understand.

Providing caring, safe, educational environments for children and adults with autism where they can learn and be productive is becoming more prevalent and imperative for our communities. The new Debra Ann November Wing of the Lerner School for Autism at the Cleveland Clinic Children’s Hospital is a benchmark facility for the programming and design of an environment specifically for people with autism, from infants to early adulthood. The 24,000-square-foot, single-story building expresses a strong modernist simplicity and clarity of purpose, with a forward-thinking image that supports one of the country’s premier healthcare institutions and its leadership in the pedagogy and treatment of autism.

Cleveland Clinic’s Center for Autism is innovative in its integration of a clinical and educational facility within a hospital setting, and in the design of its environment to support behavioral and sensory progress. As such, it serves as a model for how healthcare and community organizations can respond to the growing demand for and understanding of this highly specialized, experiential field of practice, and as a model for how to program and design environments for people with autism-a learning process even as such facilities are being built.

Located on the Shaker Heights campus as part of the Cleveland Clinic Children’s Hospital for Rehabilitation, the $8 million project is designed by Cleveland-based healthcare architects and engineers Westlake Reed Leskosky. Director of the Cleveland Clinic’s Center for Autism, Leslie V. Sinclair, MA/BCBA, speaks passionately about the need for centers of excellence: “We truly believe that children with autism deserve to learn at the optimum level. We are understanding what it takes to educate people with autism well, and we see the outcome of children who do not get the intensive intervention they need when they are young-they are disabled for the rest of their lives. The need to provide top-notch programs and facilities is clear, and the risk in not doing this is huge.”

The Center for Autism breaks new ground, as Sinclair emphasizes: “Our center is unique in two key respects. Most other programs focus on only one modality-medical, research, or education. Here we have woven a clinical educational facility in a healthcare setting. This is a maverick notion-bringing clinical intervention, medication, and education for people with autism all under one roof. Secondly, we are innovative in the creation of an environment designed specifically to support behavioral and sensory progress.

“We draw upon the clinical staff of the Cleveland Clinic Foundation, and as a nonpublic, private charter school, are linked with both the Ohio Department of Education and the Joint Commission for Healthcare Accreditation. Thus, our school is compliant with two sets of regulations. The whole idea of our program braiding both standards together is truly different. We are proving that it can be done. We are moving clinical design forward,” continues Sinclair, who is directly responsible for the Center-based programs, outreach, research, and development.

The Cleveland Clinic’s new Center for Autism is programmed for the widely varying needs of people with autism, for services that are highly individualized, and for outreach and family support. Serving 80 children with a staff of 100, the facility addresses eight age groups, ranging from infant and toddler to activities of daily living, as well as adult and vocational training. It includes eight classroom suites that vary in design based on the age of the students. Each suite maintains a high 1:1 teacher/student ratio. This unique and intensive program requires strict attention to the design of an environment in which every element and detail is assessed according to its potential impact on student behavior and sensory experience. The school also includes conference and training facilities in conjunction with administrative offices, activity, and dining spaces, as well as areas for speech therapy. A media room allows parents to observe children in the classroom environment from a remote location, as part of the school’s support of family involvement. A main distribution framework supports computer racks and equipment, communications, and technology for the entire campus.

Westlake Reed Leskosky worked closely with the administration and staff of the Cleveland Clinic and the Center for Autism in an intensive programming phase to provide highly organized, safe spaces that minimize distractions, control clutter, optimize acoustics and lighting, provide proper indoor air quality and temperature, prevent injury, and offer durability. Spaces also provide for the interaction of teachers and staff for each age group and are supported by technology and communications systems.

The design of the new Center for Autism for Cleveland Clinic presented an exciting challenge for the architects and the opportunity to address a new growth area in healthcare and education. As an emerging program and building type, it represents a very significant investment for institutions, and requires intensive staff involvement in a 1:1 or 2:1 ratio of teacher to student at most. Westlake Reed Leskosky asked how they, as architects, could approach the unique needs of people with autism as a design problem. How could they create the best possible environment for children with autism? The design team understood the importance of raising questions, gaining an understanding of issues, and exploring ideas with their client first.

Leslie Sinclair, Jennifer Manning, and the staff at the Cleveland Clinic are motivated and engaged professionals, knowledgeable in the field. They knew what they wanted to achieve and they inspired the architects. Together they identified and developed key criteria important in the planning and design of a center for autism.

Ronald A. Reed, FAIA, IIDA, principal and a lead designer of Westlake Reed Leskosky, notes, “We placed the overriding design goal for the Center for Autism on simplicity. Each decision related to the exterior envelope is purposeful, maintaining a clean, contemporary design that complements the forward-thinking technology and pedagogical concepts that the Cleveland Clinic is developing to help educate and assimilate the children at the school.”

“We are learning more and more about how to program and design facilities for people with autism, even as they are being designed and built,” remark Kevin Robinette, AIA, and Fran Woodland, AIA, WRL, design team members on the Center for Autism project. “As designers, we relied on the knowledge, experience, and intuition of Leslie Sinclair and her staff at the Cleveland Clinic. Under Philip LiBassi, our challenge was to maintain design integrity and meet programmatic needs in the context of budget and the creation of a neutral sensory environment.”

Ozanne Construction Company of Cleveland, Ohio, is construction manager for the $8 million project, which opened in May 2008. The Cleveland-based team included Knight & Stolar, Inc., for site work and landscape architecture, and Karpinski Engineering for technology services.

Programming: Developing criteria for the environment

By 2003, Cleveland Clinic recognized that its existing facilities for children with autism, housed within available space at the Children’s Hospital for Rehabilitation, did not meet the dramatic growth in demand and program, nor the specific needs of its users.

Leslie Sinclair recalls the internal and consumer-driven context driving the development of the project: “Our volume and revenue spoke to our need for a new center for autism. Our consumer base-the number of children and families and adults that we serve-and the number still waiting for services through us, rose dramatically in the past six years. We were growing out of spaces very rapidly or taking over spaces that were initially conceived for other purposes. We were facing an inability to retrofit spaces within the existing hospital that would be adequate and beneficial to people with autism and that would decrease symptoms due to the environment. At the Cleveland Clinic, our mission is to provide world-class service for all medical needs and disabilities. We needed the appropriate world-class facility to support this.”

Westlake Reed Leskosky was asked to design a new free-standing Center for Autism based on the firm’s strong modernist architectural vocabulary, as well as its expertise in healthcare and long-standing relationship with the Cleveland Clinic Foundation. Providing integrated architecture; mechanical, electrical, and plumbing engineering; and acoustic design, Westlake Reed Leskosky was able to achieve the clear, contemporary aesthetic desired by the Cleveland Clinic Foundation under the leadership of Dr. Toby Cosgrove, president and CEO, while providing significant value engineering to meet budget challenges.

Funding for Center for Autism programs comes in great part from the school district and revenue streams outside of families; however, funding for the new building involved a three-year campaign and gifts from the private sector and private foundations. “We worked very closely with our development office to bring potential donors and representatives from foundations into our hospital to show and explain what we are trying to achieve,” says Sinclair. “We were fortunate to receive two major gifts early on: $1 million from the Debra Ann November Foundation and $2 million from the Lerner Family Foundation.” The Center raised $5.6 million in funds by the end of 2007 for the project.

The first steps in developing the program and design of the center involved educating everyone involved about autism as a chronic disorder, and bringing each team member into the existing facility to tour the school and see the children. Because the treatment of autism is a rapidly developing field of practice, the programming for this model school involved scientific study and research, combined with the staff’s intuitive understanding gained through their experience. For example, the team needed to understand how people with autism respond to certain elements in the environment and how they can learn to filter sensory elements, as well as which elements could be minimized to achieve optimum learning capacity.

Together, the staff of the Center for Autism and designers at Westlake Reed Leskosky arrived at seven points as design criteria for an effective environment for people with autism:

1. Limit stimulation and prevent distractions

   1. Minimize the use of grids, busy patterns, and bold colors in building materials

   2. Provide spaces for one-on-one student-teacher activities

2. Control clutter, while still allowing children to make autonomous choices

   1. Provide adequate built-in storage to limit exposure of educational materials not in use

3. Control acoustics

   1. Design air-conditioning systems to minimize machine noise and air noise

   2. Provide acoustic separation between rooms

4. Provide proper indoor air quality and temperature control

   1. HVAC system to be multizone VAV system with filtration and adequate air changes

5. Prevent injury

   1. Eliminate sharp corners and projections from surfaces

   2. Provide resilient surfaces

6. Minimize perceived flicker from lighting sources

   1. Provide lighting sources that do not create a distraction

   2. Provide window treatments

7. Provide durability

   1. Use impact- and stain-resistant materials

The architects needed to design educational spaces with multiple environments to speak to specific sensory and behavioral needs of children with autism. The pulsating current of a fluorescent lighting tube, for example, can be perceived as a screaming noise to someone with hypersensitivity. In actuality, allowing the student access to a quiet room without sensory stimulation can have a very calming and necessary effect.

Leslie Sinclair recommended books to the team, such as Temple Grandin’s Thinking in Pictures and Other Reports from My Life With Autism, to help the designers translate the autistic experience into a built environment and make the intersections of how people interact with the spaces around them. Because of its “thinking in pictures” premise, the Grandin book helped the team understand how a person with autism would perceive his or her surroundings and make a direct connection with the visual and spatial environment.

Creating a neutral sensory and “dense” environment for one-on-one attention

From its modernist exterior inward, the Center for Autism communicates the simplicity and functional clarity that is essential for children with autism. Designed with the flexibility for future vertical expansion for added program space, the slab structure is precast concrete and curtainwall, and set on grade for ease of access. The building is adjacent to the existing Children’s Hospital for Rehabilitation, with a connecting link of an enclosed hallway. The layout allows for a number of the classrooms to have direct access to an internal courtyard and playground.

Behind the apparent simplicity of the Center for Autism, however, are a number of complex factors that needed to be taken into consideration-from the layout and planning of spaces to details selectively chosen for minimal negative impact on children with autism. The result models an appropriate environment in which children with autism can focus, learn, and be secure.

Located around the building’s perimeter to take advantage of natural light, teaching classrooms are partitioned into smaller spaces and have individual bathrooms and shared lunchrooms. Teaching areas are defined by the density required for the high 1:1 early childhood ratio and the 1.5:1 child-to-staff ratio for the upper school. Each classroom has one teacher and one full-time speech pathologist, and each child has an individual therapist. Time-out rooms are provided for students who need to regain control and be secure, for their own safety and that of others.

Bright, clean, and easily understood spaces have ample natural daylight. A central corridor provides circulation that wraps around common functions, such as gross motor rooms, speech therapy and training, activity rooms, food service, and dining and toilet rooms. Framed “entry portals doors” at classrooms reduce the long, linear effect of corridors.

The sensory environment is deliberately designed as neutral, with avoidance of strong patterns, rhythms, and textures that would overly stimulate or distract children with autism. Lighting, ceiling, and flooring are kept tranquil, diffused, and uncluttered, without strong visual patterns or grids. Westlake Reed Leskosky paid great attention to the selection of simple and straightforward design elements and durable materials.

An important part of creating a neutral sensory environment is related to noise and echo reduction and other acoustical control. Westlake Reed Leskosky’s in-house acoustician Ian Hoffman developed strategies and made recommendations regarding acoustic separation and noise control, such as minimizing the noise transmission from mechanical equipment and providing room-to-room acoustic separation. Thermostatic controls strategically allow for adjustments in response to the heat-and-cold sensitivity of children with autism.

Sinclair speaks to the successful aspects of the design that she says achieve a delicate balance: “Visual processing and the inability to filter out extraneous stimuli are great challenges to our children. It is difficult for our students to not focus on patterns in a carpet, the grate of a heating duct, the flicker of a fluorescent tube, or a long and linear space. The design of our new center reduces and minimizes these elements without seeming odd or abnormal. We have set the stage for them to not be distracted from learning, and yet take in some extraneous information in order to help prepare them to live in a world of normalcy.”

Accommodating an intensive program such as an autism school is vastly different from a standard school building. The design needed to provide for absolute one-on-one attention. Rather than one large classroom, the classroom is divided into smaller, closed rooms. There is more density of construction, and more focused attention on room partitions, acoustics, HVAC, and lighting requirements-not the standard schoolroom construction. The architects reviewed specific selections with the staff of the Center for Autism to confirm proper product selections, such as lighting and finishes. Also, instead of multistall toilets, there are individual toilets with space for teaching in the stall to accelerate toilet training.

The construction of the Center for Autism involved multiple phases to accelerate the schedule. An early site package provided for parking on site and allowed the building pad to be cleared of the existing parking lot. Bid packages for foundations and steel were let separate from general construction.

Measures for success

The measures for success for the Center for Autism lie in the development and progress of the children themselves. Sinclair says, “We continually collect hard data and will be carefully looking at the rate of progress the children make in the new facility. We will assess certain behavioral trends and see how the skill sets are acquired at a faster rate. One key area is that of visual self-stimulatory behavior-the over-focus on visual details in the environment. We expect that behavior will improve dramatically with the design of the Center.”

She summarizes, “This building is a dream come true. We have a beautiful design and facilities dedicated solely to people with autism. There are no limitations to what we can do here.” HD

Philip LiBassi, AIA, ACHA, is a principal and project director at Westlake Reed Leskosky, a planning and design firm with specialties in healthcare planning, architecture, and integrated engineering and technology with offices in Cleveland, Ohio, Phoenix, Arizona and Washington, D.C.

For more information, visit http://www.wrldesign.com.

Suggested Reading

1. Grandin T. Thinking in Pictures and Other Reports from My Life With Autism. New York:Vantage Books, 1996
2. Myler P, Fantacone TA, Merritt ET.“ Eliminating Distractions ,” American School and University, Penton Media ,November 1, 2003

Healthcare Design 2009 July;9(7):46-55