Autistic children experience high rates of sleep disturbance which can be chronic, severe, and have detrimental impacts on the physical health, wellbeing, and daytime functioning of children and their families. This, together with a rise in Autism prevalence, has resulted in increased demand for accessible, effective, and efficient models of delivering sleep support. While pharmacological interventions are common and effective, behavioural sleep interventions (BSI) present several advantages. These include well-established efficacy, evidence of maintained treatment effects, minimal harmful side effects, enhanced selfefficacy in caregivers, and the potential for generalisation to daytime behavioural difficulties. Therefore, BSI is recommended as the primary treatment for sleep problems in Autistic children. However, geographic isolation, cost, and travel constraints, coupled with a shortage of trained professionals, prevent access to support services for many families.

To address this need, this doctoral research, comprised of four studies, investigated the use of stepped-care and telehealth for the delivery of BSI, where less resource-intensive interventions (e.g., online parent psychoeducation) are delivered first, and mid-to higher intensity supports (i.e., group or individualised parent coaching via videoconferencing) are reserved for those who require additional assistance. Integrating the stepped-care model with telehealth has the potential to increase the number of families who can be supported and overcome barriers such as travel costs, time off work, and the need for childcare, making it an accessible, cost-effective, and timely delivery model for improving the sleep of Autistic children.

The primary objectives of the research were to: (a) determine whether parents of Autistic children could utilise online parent education to independently select intervention strategies with a high level of appropriateness and implement them with fidelity, and (b) generate positive changes in their child’s sleep. Secondary aims were to (c) ascertain the respective benefits of online group and individualised coaching as an adjunct to self-directed online parent education; (d) assess the maintenance of intervention effects; and (e) determine whether treating sleep problems via telehealth would produce collateral effects for children and their parents. The first study presents a systematic review of existing literature, identifying key components of telehealth-delivered behavioural interventions (TDBIs) for improving activities of daily living (e.g., eating, sleeping, personal hygiene practices) in Autistic children; finding that self-directed telehealth approaches can result in increased adaptive skills among Autistic children. However, in some cases, individualised coaching via videoconferencing may be necessary to achieve adequate child outcomes.

Studies 2 and 3 were applied projects involving 21 Autistic children (4 girls and 17 boys, aged 3-17 years) and their parents. A single-case AB design was used to evaluate the utility of the Good Nights Programme, a stepped-care telehealth-delivered behavioural sleep intervention (TDBSI) delivered across three consecutive support levels: 1) self-directed online psychoeducation, 2) group coaching via videoconferencing, and 3) individualised coaching via videoconferencing. With the goal of enhancing intervention efficacy, Study 3 introduced changes to the first two intervention phases. As such, parents received additional individualised guidance in the self-directed phase through the provision of individualised tip sheets, and modifications were made to content and its delivery during group coaching sessions. Findings suggest that self-directed approaches comprising written material, instructional videos, and other downloadable assessment and intervention resources are minimally effective. However, augmenting online materials with individualised tip sheets may assist parents in identifying appropriate strategies; serving as a moderately effective, yet still efficient, first step of the stepped-care model. Group coaching and individualised parent coaching via videoconferencing show promise as higher-intensity support for parents who do not achieve satisfactory results initially, and treatment effects were generally maintained at follow-up. Finally, in an investigation of potential collateral effects, Study 4 demonstrated that improved sleep as a result of participation in the TDBSI may produce several additional collateral benefits for children and their parents, including reduced emotional and behavioural difficulties and increased health-related quality of life for children, and improved sleep quality and emotional wellbeing for parents.

Overall, findings indicate TDBSI may provide an efficacious and acceptable alternative to face-to-face intervention, offering time-efficient and accessible support. Given the high prevalence of sleep disturbance in Autistic children, the convenience and accessibility of TDBSIs, and the potential for TDBSI to generate improved sleep and other collateral benefits for Autistic children and their parents, this research is clinically important. Future research should include group comparisons of the unique contributions and costbenefit analysis of each intervention phase, as well as identification of mediating and moderating factors impacting parent engagement, fidelity, and child treatment outcomes. The scalability of treatment should also be examined through open trials, using a telehealth stepped-care model to deliver BSI for Autistic children within real-world clinical settings.