Since the enactment of the Americans with Disabilities Act (ADA, 1990), many impaired Americans are no longer disabled by socially condoned disabling conditions in the built environment. However, many people with cognitive and neurological impairments continue to face significant barriers to access, due to disabling environmental hyper-sensitivity and sensory processing disorders. These people are equally protected under the ADA, therefore mitigation is required. Neuroarchitecture, where consideration of the impact of the built environment on the central nervous system informs design paradigms, must complement current ADA compliance guidelines. This paper serves to open the topic to discussion, and is a call for attention, and action, for the removal of these generally unrecognized barriers to access and the equal use and enjoyment of public facilities.

On July 26, 1990, President George H.W. Bush signed the Americans with Disabilities Act (ADA), calling it a "declaration of equality for people with disabilities," like the Declaration of Independence, bringing Americans "closer to the day when no Americans will ever again be deprived of their basic guarantees of life, liberty, and the pursuit of happiness." (The White House Office of the Press Secretary, 1990). Since the enactment of the ADA significant progress has been made in reducing barriers to access — we now see ramps, designated parking areas, and more. However, some persons with disabilities have been left out of the vision: people with cognitive and/or neurological impairments continue to face barriers to access and enjoyment of public facilities. The ADA design standards require modifications to reflect the purpose of the ADA: according equal access to all persons with disabilities. Neuro-architecture studies the effect of the built environment on the central nervous system, and may provide direction for these required revisions. This paper will draw attention to two barriers facing people with cognitive and neurological impairments, identify a direction for mitigation, and concludes with a clarion call for action.

The world of disabled persons in America has changed significantly over time: Kim E. Nielson (2012) reports that most Pre-Columbian indigenous peoples had no specific term for disability, and tended to view "disablement" in relational terms, i.e. functionality and balance between mind, body, spirit, and the outside world. (Nielson, 2012, p.3) The colonial focus of disability was by and large based on its impact on labor and economy (Nielsen, 2012, p.27); the warehousing (custodial confinement) of people with disabilities, particularly those with cognitive or neurological impairments, is well known — and continued until the 1970s, when large institutions, such as Willowbrook State School, were shut down. (Goode, Hill, & Bronston, 2013). Perhaps the most significant change, however, was the introduction of a "social model" of disability, which posits impairments, of themselves, are not disabling; disablement is the result of social and cultural influences — paraplegia is an impairment, but the lack of ramps is disabling, e.g. (Thomas, 2004; David Braddock and Susan Parish, in Albrecht, Seelman and Bury, p. 44, 2001).

The Americans with Disability Act is an acknowledgement of society's role in disablement, and started the daunting task of correcting disabling practices in employment, travel, public accommodations, and communications systems. I will focus on Title III, which governs private entities operating places of public accommodation, requiring all people (qualified as disabled, discussion will follow) have equal opportunities to access and enjoy public facilities, programs, services, etc.

The ADA was, and is, a game-changer for Americans with disabilities, however it has its limitations. Barrier free access is required in new construction, however there is no affirmative requirement for existing structures; modifications must be "readily achievable" and required access modifications need not exceed 20% of the total cost of an alteration. Enforcement remains a challenge (Switzer, 2003, pp. 126-128). David Ferleger, in 2010, noted: "For every claim, there is a defense. For every rule, there is an exception." (p.4). Congress recognized a dependence on "private enforcement", thereby putting the onus on individuals — and creating a backlash, because some attorneys and "professional plaintiffs" were exploiting requirements under the ADA to generate out-of-court settlements (and personal profits) (Milani, 2001).

The costs associated with compliance, particularly in the case of alterations to existing buildings, have been repeatedly cited as an obstacle to ADA compliance; an evaluation supplied by the Small Business Administration in 2007 estimated barrier removal costs (baseline) per square foot, in various public settings, would range from $0.39 to $10.92 (based on then-current "RS Means" estimated costs). On the other hand, Shapiro, (1994, pp. 70-71) discussing barrier removal under Section 504, noted real costs are substantially lower than estimates: the state of North Carolina estimated spending $15 billion for compliance; costs actually came to $15 million. Marmot (2002), writing about health-care settings, called for follow-up studies of design standards, noting the lack of study is cost-driven; however, studies allowing prediction of design flaws in the design-phase would save money, while actually correcting any identified flaws post-construction would be costly.

The ADA does not rely on set diagnoses as determinates of disability. Rather, at §12102, the operant definition of disability is a "physical or mental impairment that substantially limits one or more major life activities" (or a record of such impairment, or the perception that the person has such an impairment.) Major life activities include "concentrating, thinking, communicating… and/or operation of major bodily functions," including neurological. Note: at (4)( E)(i): the determination of disability "shall be without regard to the ameliorative effects of mitigating measures" including medications, assistive technology, and "learned behavioural or adaptive neurological modifications."

The National Council on Disability is charged with releasing progress reports on the implementation of the ADA. The report from 2007 noted, in the Executive Summary:

People with physical disabilities have seen steady, although inconsistent, progress in access to public accommodations, including restaurants, theaters, stores, museums, Web sites, and government services. People with sensory or communication disabilities were less likely to report experiencing progress in access to public accommodations.

Hyper-sensitivity to light and sound creates a significant barrier to equal access, use and enjoyment. Fougeyrollas and Beauregard (in Albrecht, et al., 2001, pp. 171-194), present "Major Environmental Factor Categories" disabling individuals, in two groupings: social factors (political/economic and socio-cultural), and physical. Physical factors include sound and lighting, as well as architectural and technological developments. A tacit acknowledgement of these barriers is found in advice to mediators of ADA disputes to consider accommodating persons with photo- and aural-sensitivity. Significantly, this is from a report crafted under the combined efforts of the National Council on Disability, the Equal Employment Opportunity Commission, and the U.S. Department of Justice (Questions and Answers for Mediation Providors…" n.d.).

Sound and light are tied to sensory processing disorders; co-incidence with developmental and behavioral disorders such as schizophrenia and autism was noted by the American Academy of Pediatrics (2012). Cheng and Boggett-Carsiens (2005) point to sensory processing disorders (sound and touch) as a source of "explosive" behaviors, using their case study of a nine-year-old boy. Parra, Kalitzin and Lopes de Silva (2005) tie qualities of lighting (luminescence and wavelength) to seizures, and go on to call for controls of "provocative" materials.

Anecdotal reports attest to the disabling impact of light and sound, with the subjective experience described in one case as "so painful going out of the house is out of the question" (describing hyper-acusis, in "20/20 My Strange Affliction, 2014). "K.N." (2013) related her experience with a sound-triggered seizure, specifically calling the setting a barrier to access; Saroya (2013) described her experience with sensory overload as a "violent assault." Participants in the "Close to the Wall' project (Tuckett, Marchant and Jones, 2004), described sensory overload as "painful" and, in some cases leading to a "catatonic" mental shutdown. (p.20); this report advises us that "noise is to people with dementia what stairs are to people in wheelchairs." (p.18). My personal experiences with children with developmental disabilities, involving sensory-triggered meltdowns and photogenic absence seizures, has led my family to eschew many venues and settings due to poor acoustics and problematic light. (Appendix, Author, 2013). "Su" (2013) and "JoDay" (2014) related their experiences with photosensitive epilepsy: Su is afraid to leave her home, while JoDay, a plumber, tells of backing into any bathroom with fluorescent lights, hoping to avoid photogenic seizures. These anecdotes draw a clear picture of specific, controllable sensory stimuli causing some people with disabilities to avoid certain settings, effectively denying them equal opportunities to access and enjoy public facilities, programs, and services.

These reports describe the disabling effects of light and noise on the central nervous system. While inclined planes (ramps) have been widely, and successfully, employed to get people with mobility impairments through the front door, using a 'technology' available since prehistoric times; more recent studies in the field of neurology, and specifically the discipline of neuro-architecture, provide insights and solutions for these barriers to access.

Neuro-architectural design paradigms reflect an awareness and consideration of the impact of design (the 'built environment') on the central nervous system. The Academy of Neuroscience for Architecture (ANFA), formed in 2003 under the auspices of the American Institute of Architects, actively promotes the practice of neuro-architecture and supporting research. Their web site, www.anfarch.org, offers a foundational review, as well as insights into the latest developments in the field. Neuro-architecture is entering the mainstream; in 2012 Pacific Standard printed "Corridors of the mind: Could neuroscientists be the next great architects?" (Badger, 2012); subsequently The New York Times weighed in with "Why we love beautiful things" (Hosey, 2013). Both articles point to advantages in healthcare settings and schools, however they do point to future applications, hinting at the possible stress reduction, enhanced cognition, and the deliberate "scientific" design of artwork based on an understanding of the neurological response to set patterns, colors, dimensions, etc.

There is a long-standing awareness of the implications of design considerations for specific settings. For example Yanni (2007) tells the story of Dr. Thomas Kirkbride, responsible for the Kirkbride-plan asylums popular throughout America in the late 1800s. These palatial, estate-like institutions were carefully designed as healthful sanctuaries, intended to promote healing (p.15). Dr. Kirkbride was one of the founding members of what would become the American Psychiatric Association. In an interesting development, in 1875 Edward Spizka, a neurologist, charged the APA with non-scientific, frivolous distractions — such as architecture, and being "experts at everything except the diagnosis, pathology, and treatment of insanity." (Yanni, 2007, p.143).

Neurological implications are a critical consideration in the design development for healthcare facilities. Alexi Marmot (2002), writing about healthcare settings for the British Journal of General Practice in "Architectural determinism: Does design change behavior?" concluded that, yes, it probably does, and called for further study. In 2012 Ulrich, Bogren and Lundin submitted: "Toward a design theory for reducing aggression in psychiatric facilities" — an empirical study on the effect of specific design paradigms on psychiatric populations to ARCH 12, a conference on Architecture/Research/Care/Health. Dr. Eve Edelstein, holding advanced degrees in both neurology and architecture, is a Research Associate with ANFA. The ANFA web site credits her with six published studies in the period 2007 through 2009, all related to healthcare environments.

With "Translational design: The relevance of neuroscience to architecture," Edelstein, (2005) presented an overview of neuro-architectural design applications in healthcare settings, noting the relationship between lighting and circadian rhythms, to the American Society for Healthcare Engineering (part of the American Hospital Association). The disruption of circadian rhythms is often, although not universally, tied to "sundowning" - the behavioral aberrations displayed in the late day/early evening among the elderly with dementia. Photo-therapy, combined with careful consideration of natural and artificial light sources when designing facilities specializing in assisted living for the elderly, may reduce these difficult behaviors, to the benefit of the seniors and staff. (Khachiyants, Trinkle, Son, and Kim, 2011).

Noise reduction was deemed a valued design consideration by Ulrich et al., based on studies in non-psychiatric healthcare environments. (2012, pp. 4-5). "Acoustics in healthcare environments", a whitepaper for design professionals prepared by the Ceilings and Interior Systems Construction Association (CISCA) (n.d.), discussed the need for acoustic design considerations to promote patient recovery, reduce stress for both staff and patients, and preserve confidentiality. The problems associated with noisy mechanical equipment are noted.

There are many sources for literature specifying design and performance standards, including lighting and acoustics, for healthcare environments. Product manufacturers, and their associations (i.e. CISCA) provide reports, classes (with accredited continuing education units for design professionals), and cut-and-paste CAD (computer-aided-design) specifications. The public and private entities charged with constructing and operating healthcare facilities have produced massive manuals, guidelines for design practices to maximize building efficiencies and, at the same time, support optimal patient outcomes. Various professional groups, including the American Institute of Architects and the American Society for Healthcare Engineering, print reference guides and "best practice" reports; they also conduct outreach and training. Finally, the American National Standards Institute (ANSI) is deemed the gold standard in design specification. ANSI publications are available with specific consideration of lighting and acoustic requirements for healthcare settings, as well as ADA requirements.

Similarly, a great deal of attention has been given to to the effects of the sensory impact of design in school environments. Students, pedagogical and non-pedagogical staff, in both general education settings and those dedicated to specific student populations, are affected by poor lighting and sound designs. Careful consideration of the effect of sound and lighting has a positive effect on student achievement and outcomes.

In 1999 the Access Board responded to a petition for rulemaking on classroom acoustics. (Architectural and Transportation Barriers Compliance Board; Petition for rulemaking; Request for information on acoustics, 36 CFR Chapter XI [Docket No. 98-4], 1998); noting the undeniable impact of both background noise and reverberation on student outcomes, the Board formed a working group to develop recommendations for standards. The Access Board has entertained this request for rulemaking on acoustics standards for classroom settings only; other venues have not been considered. As of April 2014, no rules have been promulgated.

Nelson, Soli and Seltz (2002) considered acoustic design in general education settings, however, they noted students with disabilities, including auditory processing disorders, behavior problems, and intellectual disabilities, underline the need for controlled acoustics. They called for reduced reverberation, and quieter learning environments. Magda Mostafa, in "An architecture for autism: Concepts of design intervention for the autistic user" (2008) created a design matrix to organize the characteristics of the built environment around the sensory issues found among students with Autistic Spectrum Disorders. Her goal was to promote settings that support efficient and effective behavior modification programs. Writing for teachers on the National Education Association website, Lorain (n.d.) calls for middle-school design elements for acoustic buffering and natural lighting. Mortice ("Absolutely Accessible," 2011) tells us the "next frontier" of universal design (i.e. products and environments usable by all people) will include consideration of cognitive and sensory impairments. He uses a school in Maryland to illustrate his point. In "Influences of School layout and design on student achievement", Tanner (2013, in Hattie and Anderman) notes the importance of lighting, and ties fluorescents with seizures (p.139).

As with healthcare, literature regarding design standards for education settings is readily available. State, and often local, governments have detailed standards for school construction and alterations. Professional associations, including the American Institute of Architects, and the Acoustical Society of America have released publications and conduct training in the design and performance standards expected for schools. Manufacturers of materials used in school construction (lighting, acoustic tiles, carpeting, etc.) provide information, training, specifications, and cut-and-paste CAD (computer-aided-design) specifications. ANSI provides direction on performance criteria, standards, and design requirements specific to classrooms and education settings.

Specialized housing design, particularly for adults on the Autistic Spectrum, has also prompted consideration of the sensory environment in design development. Ahrentzen and Steele (2009) seek to advance "full spectrum" housing for adults with Autisitc Spectrum Disorders. To compensate for sensory processing disorders, they call for "sensory neutral" designs, calling attention to disturbing humming appliances and flickering fluorescent lights. (p.23).

The literature from the healthcare, education, and specialized housing disciplines of architectural design give us hope: methods and materials for barrier mitigation are available and in use. Indeed, in the case of acoustic controls, those measures have been steadily evolving since the beginning of the twentieth century. In Chapter 5 of The Soundscape of Modernity (2002, pp. 169-227), Thompson traces the evolution of acoustic design in America from 1900 to 1933; noise attenuation was the goal for residential and commercial venues. Currently, the Ceilings & Interior Systems Construction Association (n.d.) recommends various acoustic ceiling tiles (ACT) for noise attenuation (pp. 15-16). Ahrentzen and Steele (2009) call for the specific use of non-fluorescent bulbs (p.45), quiet mechanical systems, and soundproofing materials (p. 49). The chapter on "Architectural Acoustics" in The Architect's Handbook of Professional Practice, (Jaffe & Cooper, 2000) addresses mitigation and attenuation, using both space configuration formulas and specific materials. Similarly, Lighting Design Basics (Karlen, Benya and Spangler, 2004) discusses the problems often found in ballast/transformer assemblies, often the source of flicker and hum. An overview of different systems, and wavelength and luminance values (essentially, how much light falls in a specific area within a given solid angle), is provided. ANSI specifies acoustic materials for controlling reverberation and sound absorption, as well as specifying lighting solutions for different applications.

A report from the United Kingdon, Cognitive impairment, access and the built environment (Tuckett, Marchant, and Jones, n.d.) indicated the most promising research in design principles meeting the needs of people with cognitive impairment comes from studies of residential care settings for the elderly, schools, and health-care settings for the acutely ill. The authors credit Americans with the "universal design" concept; British architects favor "inclusive design." They note that most architects think exclusively in terms of mobility and, to a lesser extent, impairments to vision or hearing, when asked about creating access for people with disabilities. This is a collaborative, participatory report: professionals working with people with neurological impairments to identify problems and identify possible solutions.

Monica Ponce de Leon, dean of the School of Architecture and Urban Planning at the University of Michigan noted "…unfortunately [in] academia design for the disabled has been thought of as the requirement that we need to fulfill in order to get accreditation as a school." (All Things Considered, 2010). A 1998 study of architects in Britain found "little or no notion of what a disability is, or, alternatively, a broad-based conception relating to an exclusive set of impairments." (Hall and Imrie, 1999, p.412). Predictably, 84% always consider accessible toilets, 62% always consider ramps and level entries, none of the respondents said these were never design considerations. I submit the response, limited though it may be, may be based on awareness prompted by the passage of the Disability Access Act of 1995. While this study showed an awareness of physical impairments in design, it illustrates a woeful lack of concern for the needs of persons with cognitive impairments - only 8% always considered their needs, 21% sometimes, 32% rarely, and 28% never. (Hall & Imrie, 1999, p. 414).

Those attitudes are changing, slowly but surely. Many players are involved in the creation of our built environment: architects, developers, end-users, and regulators. This is not a faceless group — you will find individuals personally invested in promoting access, due to their own impairments or those of family members. They are perceived as a small group, and they seem to face an uphill battle for broader influence in design standards.

A comparison of the awareness of disability in design with the trajectory of eco-awareness ("green building") is instructive. The US Green Building Council (USGBC) was formed in 1993, three years after the ADA was signed. While USGBC is a non-profit organization, it presents a classic example of successful marketing. The group created the Leadership in Energy and Environmental Design (LEED) certification system, which awards different levels of certification for design outcomes. Environmentalists love it — but more importantly, corporations — both developers and end-users, have found these certificates lend cachet to their brands. Architects and engineers proudly proclaim their status as "LEED® Accredited Professionals" and, within the last several years, local governments and municipalities have incorporated "green building" standards in the regulations. Unlike disability access, we now find awareness of environmental impact informing every level of construction, from siting to design to materials, with competitive efforts to improve on existing standards.

The success of USGBC could be duplicated in the realm of disability access design — the same incentives apply. Certificates for various levels of compliance would promote competitive efforts for fully accessible buildings. "Disability Design Professional" accreditation and continuing education programs could be offered, addressing the concerns voiced by Dean Ponce de Leon. There is no need for regulatory "catch-up" -the "stick" offsetting the marketing "carrot", because compliance mechanisms already exist in the ADA and local rules and regulations.

Owner/operators of retail and performance venues are learning that accommodation of people with disabilities, in general, is a powerful marketing tool. In 1997, Menzel-Baker and Kaufman-Scarborough noted that "the number of people with disabilities in the United States [20%] is more than the populations of California, Florida, and Iowa combined" — indeed, at that time, the percentage of Americans with disabilities, estimated at roughly 20%, was greater than the percentages of Black (12.4%) or Hispanic Americans (12.5%)! Clearly, persons with disabilities represent an enormous group of potential customers. Responsive retailers found repeat custom and loyalty rewarded their efforts to accommodate persons with disabilities, and also helped them avoid costly litigation. (Baker & Kaufman-Scarborough, 2001, p.297 et seq.)

Currently, live performance and cinema theaters are offering "sensory-friendly" performances, in recognition of the growing numbers of children with sensory-processing disorders (and their doting parents and grandparents). The Autism Theater Initiative, supported by the Theater Development Fund (www.tdf.org) , has promoted sensory-friendly performances of Broadway productions since 2011; AMC Theaters has been presenting autism-friendly screenings of G and PG rated movies once a month since 2009 (Goehner, 2010)

In conclusion, many facilities present barriers engendered by cognitive and/or neurological conditions, which can, and must, be corrected. This paper is a wake-up call for design professionals, the operators of public facilities, marketing firms, and others , who are all missing significant opportunities to expand their contributions in their respective fields. This paper is also a shot across the bow of the disability community, seeking to bring attention to a significant gap in protections afforded by the Americans with Disabilities Act. There is clearly a cause of action for this failure to address their right to a barrier-free environment, or at the very least a reasonable accommodation of their needs. I open the topic for further discussion, and action, among practitioners of law and architecture, as well as advocates, individuals, and property owners. As this discussion progresses, further study will map the path towards resolution of this injustice.


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Appendix: A Personal Story

Neuro-Architecture and Access for All

Join me on a family outing — a trip to watch a family friend play in an intermural basketball game - with my three extra-ordinary children. The oldest uses a wheelchair to get around; he is neuro-typical. The next is an aspiring young athlete with Downs Syndrome. The youngest is a handsome young man on the autism spectrum, who is also subject to photo-sensitive seizures. Travel is not a problem: accessible transportation is available, the middle child is quite taken with the role of "commuter", and the youngest loves trains.

At the gym, my family gets court-side seating, provided to accommodate the wheelchair. The game begins. A whistle blows, the crowd roars: sounds echo off the walls. The middle child drops to the floor in a fetal position, hands over her ears, crying… only her family notices. Meanwhile, the youngest is also affected by the noise, and begins rocking and flapping his hands while growling, prompting questioning looks from people in the immediate area. He then goes completely still: an absence seizure, prompted by the flashing lights on the scoreboard.

Exit family — except the oldest, who stays and enjoys the game — and a fully accessible environment. While these three people are all defined as "disabled" under the Americans with Disabilities Act, only one is afforded barrier-free access to, and enjoyment of, this "public accommodation and facility."

That is wrong.

This family — my family! — is a cross section of disability, representing physical, mental, and neurological impairments. Like all families, we are a single unit, with differing individual strengths and needs. We are a family. We should be able do things together, right?

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Copyright (c) 2015 Victoria Gillen

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