RESEARCH ARTICLE

The Social Responsiveness Scale in Relation to DSM IV and DSM5

ASD in Korean Children
Keun-Ah Cheon, Jee-In Park, Yun-Joo Koh, Jungeun Song, Hyun-Joo Hong, Young-Kee Kim,
Eun-Chung Lim, Hojang Kwon, Mina Ha, Myung-Ho Lim, Ki-Chung Paik, John N. Constantino,
Bennett Leventhal, and Young Shin Kim

The Social Responsiveness Scale (SRS) is an autism rating scales in widespread use, with over 20 official foreign language
translations. It has proven highly feasible for quantitative ascertainment of autistic social impairment in public health
settings, however, little is known about the validity of the reinforcement in Asia populations or in references to DSM5.
The current study aims to evaluate psychometric properties and cross-cultural aspects of the SRS-Korean version (K-
SRS).The study subjects were ascertained from three samples: a general sample from 3 regular education elementary
schools (n=790), a clinical sample (n=154) of 6–12-year-olds from four psychiatric clinics, and an epidemiological sam-
ple of children with ASD, diagnosed using both DSM IV PDD, DSM5 ASD and SCD criteria (n=151). Their parents com-
pleted the K-SRS and the Autism Spectrum Screening Questionnaire(ASSQ). Descriptive statistics, correlation analyses
and principal components analysis (PCA) were performed on the total population. Mean total scores on the K-SRS dif-
fered significantly between the three samples. ASSQ scores were significantly correlated with the K-SRS T-scores. PCA
suggested a one-factor solution for the total population.Our results indicate that the K-SRS exhibits adequate reliability
and validity for measuring ASD symptoms in Korean children with DSM IV PDD and DSM5 ASD. Our findings further
suggest that it is difficult to distinguish SCD from other child psychiatric conditions using the K-SRS.This is the first
study to examine the relationship between the SRS subscales and DSM5-based clinical diagnoses. This study provides
cross-cultural confirmation of the factor structure for ASD symptoms and traits measured by the SRS. Autism Res
2016, 00: 000–000. V C 2016 International Society for Autism Research, Wiley Periodicals, Inc.

Keywords: Korean social responsiveness scale; validity; reliability; DSM IV PDD; DSM5 ASD

Introduction neurodevelopmental disorders [Maenner et al., 2014].

These changes include: (1) Elimination of Pervasive
Autism spectrum disorder (ASD) is characterized by early- Developmental Disorder (PDD) and the five PDD sub-
onset, pervasive impairment in social reciprocity/com- types found in DSM IV; (2) Creation of the new, diagnos-
munication and the presence of restricted interests and tic category, ASD, that is adapted to the individual’s
repetitive behaviors (RRB), with prevalence ranging from clinical presentation by inclusion of clinical specifiers
1.4 to 2.6% in the previous studies using community and “associated features,” such as intellectual impair-
samples [APA, 1994; Autism and Developmental Disabil- ment and/or language impairment, motor deficits, self-
ities Monitoring Network Surveillance Year 2010 Princi- injury, disruptive/challenging behaviors, anxiety, and
pal Investigators, 2014; Kim et al., 2011; Maenner et al., depression;(3) Changing from the DSM IV PDD three
2014; Zablotsky, 2015]. In the American Psychiatric Asso- domain criteria that included social reciprocity, commu-
ciation (APA) Diagnostic and Statistical Manual for Men- nication and restrictive, and RRB to two DSM-5 ASD
tal Disorders, 5th Edition (DSM-5) released May 2013, domain criteria composed of social communication/
changes include major alterations in criteria for interaction and RRB; (4) For DSM-5, inclusion of sensory

From the Division of Child and Adolescent Psychiatry, Department of Psychiatry & Institute of Behavioral Science in Medicine, Yonsei University
College of Medicine, Seoul, Korea (K.A.C., J.I.P.,); The Korea Institute for Children’s Social Development and Rudolph Child Research Center, Seoul,
South Korea (Y.-J.K., E.-C.L.,); Department of Psychiatry, Ilsan Hospital, National Health Insurance Corporation, Goyang, South Korea (J.S.,); Depart-
ment of Psychiatry & Suicide and School Mental Health Institute, Hallym University College of Medicine, Sacred Heart Hospital, Anyang, Korea (H.-J.H.,);
Yonsei Bom Private Psychiatric Clinic (Y.-K.K.,); Department of Preventive Medicine, Environmental Health Center (Neurodevelopment), Dankook
University College of Medicine, Cheonan, South Korea (H.K., M.H.,); Department of Psychiatry, Environmental Health Center (Neurodevelopment),
Dankook University College of Medicine, Cheonan, South Korea (M.-H.L., K.-C.P.,); Department of Psychiatry, Washington University School of
Medicine, St. Louis, Washington (J.N.C.,); Department of Psychiatry, School of Medicine, University of California, San Francisco, California (B.L.,
Y.S.K.,); Department of Psychiatry, Yonsei University College of Medicine, Seoul, South Korean (B.L., Y.S.K.)
Received May 22, 2015; accepted for publication June 20, 2016
Address for correspondence and reprints: Young Shin Kim, Department of Psychiatry, School of Medicine, University of California, San Francisco,
Langley Porter Psychiatric Institute, LP-377, 401 Parnassus Avenue, Box 0984, San Francisco, CA, 94143-0984. E-mail: [email protected]
Published online 00 Month 2016 in Wiley Online Library (wileyonlinelibrary.com)
DOI: 10.1002/aur.1671
C 2016 International Society for Autism Research, Wiley Periodicals, Inc.
V

INSAR Autism Research 00: 00–00, 2016 1

symptoms in the RRB domain criteria; and (5) For DSM- special education [Charman et al., 2007]. Duvekot, van
5, changing the specification of the age of onset from der Ende, Verhulst, & Greaves-Lord [2015] reported that
“age three” to “early childhood.” Additionally, DSM-5 the SRS, based on parent report, demonstrated excellent
adds a new diagnostic category, “Social Communication correspondence to an ASD classification according to
Disorder (SCD).” SCD appears to include individuals who the Developmental, Dimensional, and Diagnostic Inter-
primarily have problems with the pragmatic aspects of view (3 Di), and both the 3 Di and ADOS.
social communication that adversely impact social The psychometric properties of the SRS have been
behavior/adaptation. According to DSM-5, individuals examined extensively in clinically-ascertained individu-
with SCD have difficulties similar to ASD but these prob- als with ASD. Clinical samples are often compromised
lems are solely restricted to the realm of social communi- by biases related to severity, comorbidity, and access to
cation and do not include the DSM5 RRB criteria found health care [Gerhard, 2008]. Indeed, our ASD preva-
in ASD [Maenner et al., 2014]. lence study [Kim et al., 2011], using a total population
Apparent differences between DSM IV PDD and DSM5 approach, demonstrated that there are distinct differ-
ASD criteria have led to an interesting challenge in the ences in the characteristics of children with ASD who
use of existing ASD screening questionnaires for DSM5 have received clinical/educational services (the clinical
ASD. Established screening instruments have typically sample of ASD) versus those who did not (nonclinical
been validated for DSM IV PDD diagnoses; there are few sample). For example, among children from the clinical
published reports on the relationship between existing setting, 72% were diagnosed with the most narrowly
screeners and their application to DSM5 ASD, and SCD defined syndrome, Autistic Disorder (AD),the male to
diagnoses [Mayes, Black, & Tierney, 2013; Mayes et al., female ratio was 5:1, the mean performance IQ (PIQ)
2014]. Screeners with established psychometric proper- was 75 6 28, and the T-scores on the Behavioral Assess-
ties for both DSM IV PDD and DSM 5 ASD will be useful ment System for Children II Parent Rating Scales (BASC
for clinical care and clinical research efforts during this II-PRS; [Reynolds & Kamphaus, 2004]) adaptability sub-
period of transition from DSM IV to DSM 5. scale was 38 (general population mean 5 50). In sharp
Early identification of children with ASD in the com- contrast, of those children with ASD from a nonclinical
munity is crucial to providing early intervention. Effec- sample, only 28% met criteria for AD, the male to
tive and efficient screening instruments play a critical female ratio was 2.5:1, the mean PIQ was 98 6 19, and
role in the early identification of children with ASD. The mean T-score on the BASC II-PRS adaptability subscale
Social Responsiveness Scale (SRS), a 65-item scale, com- was 43. These differences suggest that unbiased,
pleted by parents and/or teachers, has been extensively population-based samples that represent a broad distri-
used as a screening instrument in the general population bution of the ASD phenotype are essential to develop
and as an aid to clinical diagnosis of ASD [Constantino and validate effective ASD screening instruments.
& Gruber, 2012]. While the SRS, like most screeners, Cross-cultural validity of the SRS has been established
aims to predict a diagnosis of ASD itself, it has an added in a large German sample [Bolte, Poustka, & Constantino,
benefit of providing a quantitative score for social 2008] and a UK general population of children [Wigham,
impairment in ASD; this allows for comparisons across McConachie, Tandos, Le Couteur, & Gateshead Millenni-
settings and against norms that can be standardized um Study core team, 2012]; published data for Asians are
with different raters [Constantino & Gruber, 2012; Con- limited to Japanese children from a clinically-identified
stantino et al., 2003a]. Additionally, the SRS has the abil- ASD sample and typically developing children [Kamio
ity to quantify subtle differences in the degree of et al., 2013] as well as a Taiwanese preschool population
impairment, strong reliability across various informants, recruited from a clinical setting and community [Wang,
stability of interindividual differences over the course of Lee, Chen, & Hsu, 2012].
years, and minimal correlation with IQ [Constantino & Finally, to date, there are no validated screening
Gruber, 2012]. Pronounced elevations in SRS scores on
instruments available for use with DSM-5 ASD and SCD
the order of 2–3 standard deviations greater than popula-
diagnoses.
tion means are highly predictive of an ASD diagnosis,
but not with the diagnosis of other child psychiatric dis-
orders [Constantino, Hudziak, & Todd, 2003b]. Materials and Methods
Several previous studies suggest the utility of the SRS Subjects
as a diagnostic screener for ASD. Aldridge et al. used
This study involves three independent samples.
SRS in a tertiary level, autism spectrum disorder assess-
ment clinic [Kamio et al., 2013]. Charman and his col- 1. General Sample: The sample was children
leagues also reported that the SRS showed strong to between the ages of 7 and 12 years (born between
moderate ability to identify autistic-spectrum disorder 1996–2003) and attending three elementary schools in
in an at-risk sample of school-age children receiving Cheon-An city from year 2009–2010. Cheon-An, with

2 Cheon et al./Social responsiveness scale in Korean ASD INSAR

 a population of approximately 600,000, is located in ages of 4 and 18 years. It aims toreliably identify a wide
the northeast corner of Chungcheong province, South spectrum of deficits in reciprocal social behavior, rang-
Korea. Cheon-Anis characterized by a concentration ing from absent to severe, based on observations of a
of high tech company headquarters, resulting insome- child’s behavior in naturalistic social settings. It is a 65-
what higher levels of educational and socioeconomic item questionnaire that is completed by teacher, a par-
status of the residents when compared to the general ent, and/or another adult caregiver. Scoring is on a
population in Korea. Parents of 817 students out of four-point Likert Scale. Five subscales are also provided:
eligible 1711 children at participating schools Social Awareness (AWA), Social cognition(COG), Social
returned questionnaires. After excluding the students Communication (COM), Social Motivation (MOT), and
who were outside the 7–12 years age range and those Autistic Mannerism(MANN). The SRS also generates the
with missing data (N 5 27), the final participants DSM-5 ASD subscale scores: Social Communication
included 790 students (412 Male, 378 Female). Index (SCI) is indexed by AWA 1 COG 1 COMM 1 MOT
2. Clinical Sample: The clinical sample included and RRB Index (RRBI) is indexed by MANN [Constantino
7–12-year-old children who were born between 1998– & Gruber, 2012]. We note that the derivation of the
2004 and evaluated at a child and adolescent psychiatry DSM-5 subscales is described in the SRS-2 manual [Con-
clinic in four university/university-affiliated medical stantino & Gruber, 2012], and that the item content of
centers during 2010–2011. A Korean Board Certified the SRS and the SRS-2 for 4–18-year-olds is identical. The
Child and Adolescent Psychiatrist evaluated all of the only differences relate to T-scores generated by the
children in outpatient clinics and made clinical diagno- instrument, which were updated in the latter version on
ses based on DSM-IV criteria. The total number in the the basis of more complete acquisition of U.S. standardi-
clinical sample was 154 (118 Male, 36 female). Diagnoses zation data.
included ADHD (62%), Disruptive Behavior Disorders In its primary application, the SRS demonstrated a
(ODD1CD: 3%), Tic Disorder (12%), Anxiety disorder singular, continuously distributed underlying factor,
(8%), Depressive Disorders (7%), and others (3%), resulting in disparate phenotypic manifestations across
with25% having multiple diagnoses. the three criterion domains for autistic disorder (social
3. Epidemiological Sample of ASD: 151, 7–12-year deficits, language deficits, and repetitive/stereotypic
old children born between 1993 and 2000 and con- behaviors), as well as generating a Total Score for all 65
firmed to have DSM IV PDD, or DSM-5 ASD (n 5 133) questions; sex-specific SRS total raw score cut points
and SCD (n 5 16) were ascertained during 2006–2010 have been recommended [Constantino et al., 2004]. For
from a total-population prevalence study of ASD in a males, a cut-point of 70 for the SRS total raw score is
metropolitan Seoul suburb. All 7–12-year-old children recommended for the purpose of screening for any
in the target city (N 5 55,226) were screened with par- autism spectrum condition (PDD-NOS, Asperger’s Disor-
ent- and/or teacher-reports using the Autism Spectrum der, or Autistic Disorder) in school or other general
Screening Questionnaire (ASSQ) [Kim et al., 2011]. For population group. Similar levels of sensitivity and spe-
children who screened positive (parental ASSQ scores cificity are achieved when an SRS total raw score cut-
in upper 5th percentile and/or teacher ASSQ scores point of 65 is used for females.
10), confirmatory diagnostic assessments were con- For the current study, the SRS was translated into
ducted with the Autism Diagnostic Observation Korean by a team of researchers, including child and
Schedule (ADOS), the Autism Diagnostic Interview- adolescent psychiatrists and clinical psychologists. The
Revised (ADI-R) and cognitive testing. Best-estimate translation team translated the SRS into Korean, and
clinical diagnoses for subtypes of DSMIV PDD, DSM-5 the Korean version of the SRS was then back-translated
ASD and SCD, along with comorbid conditions, were into English by a bilingual child psychiatrist. The back-
generated by teams of child psychiatrists and/or a translated version was reviewed and reconfirmed by a
child psychologist, after all relevant data were child and adolescent psychiatrist at the University of
reviewed (Table 1). (Details can be reviewed in the origi- California San Francisco. After completing the transla-
nal report [Kim et al., 2011]. Approved by the Yale Uni- tion and back translation, the translation team modi-
versity IRB in US, as well as Yonsei, Hallym, Kwandong, fied the instrument based on a series of detailed
and Dankook Universities and Ilsan Hospital IRBs in discussions about areas that needed to be adjusted in
order to address specific cultural differences. For exam-
Korea, the present study was conducted between 2005
ple, item 36 (has difficulty in relating to adults) was
and 2011.
translated into Korean “has difficulty in making social
Measures relationships with adults,” because the direct transla-
tion did not convey an accurate meaning. In order to
SRS [Constantino & Gruber, 2005]: The focus of the examine the feasibility of using this instrument
SRS is the behavior of a child or adolescent between the (parents’ understanding of questions and time needed

INSAR Cheon et al./Social responsiveness scale in Korean ASD 3

 4
Table 1. Demographic Characteristics and the K-SRS Scores of Three Samples
Epidemiological ASD sample
(n 5 151)

General sample Clinical Sample DSMIV PDD DSM5 ASD DSM5 SCD
(n 5 790) (n 5 154) (n 5 151) (n 5 133)c (n 5 20)c
M F M F M F M F M F
Sex (n 5 412) (n 5 378) (n 5 118) (n 5 36) (n 5 119) (n 5 32) (n 5 107) (n 5 26) (n 5 11) (n 5 9)

Age /mean 9.08(1.70) 9.13(1.74) 9.42(2.50)b 10.76(3.03)b 10.31(1.74) 10.20(1.92) 10.19(1.70) 10.77(1.90) 10.27(1.70) 10.89(1.76)
(S.D)
K-SRS raw score [K-SRS T-score] /Mean (S.D.)
AWAa 6.89(2.84) 6.26(3.09) 7.53(3.30) 7.17(3.01) 9.63(3.93) 8.69(3.05) 9.91(3.84) 8.92(3.30) 7.91(3.59) 6.78(1.72)
[51.02(9.55)]b [48.89(10.37)]b [53.15(11.09)] [51.94(9.55)] [60.21(13.21)] [57.05(10.25)] [61.14(12.90)] [57.84(11.07)] [54.43(12.05)] [50.64(5.76)]
COGa 8.03(4.39) 7.48(4.34) 9.19(6.10) 10.64(6.87) 15.69(6.98) 13.81(4.90) 16.40(6.77) 14.27(4.86) 9.36(4.97) 8.56(6.29)
[50.60(10.04)] [49.35(9.92)] [53.25(13.94)] [53.25(13.94)] [68.14(15.97)] [63.84(11.20)] [69.77(15.49)] [64.89(11.13)] [53.66(11.36)] [51.81(14.40)]
COMMa 10.81(6.35) 9.46(6.22) 15.18(9.28) 17.28(12.42) 25.66(12.47) 25.00(10.77) 26.82(12.00) 26.62(10.82) 15.18(10.93) 14.00(8.62)
[51.02(10.05)]b [48.89(9.84)]b [57.93(14.67)] [61.25(19.64)] [74.51(19.72)] [73.47(17.04)] [76.36(18.99)] [76.03(17.12)] [57.94(17.30)] [56.07(13.63)]
MOTa 5.98(3.30) 6.05(3.21) 7.31(5.03) 9.25(5.56) 12.25(5.51) 13.60(5.55) 12.51(5.60) 14.12(4.64) 9.36(4.46) 8.22(8.30)
[49.89(10.13)] [50.12(9.87)] [53.97(15.44)]b [59.94(17.07)]b [69.16(16.94)] [73.28(17.03)] [69.97(17.19)] [74.88(14.26)] [60.29(13.68)] [56.79(25.50)]
MANN (RRBI)a 3.08(3.38) 2.44(2.83) 6.56(5.66) 8.47(6.98) 11.92(6.97) 11.47(5.68) 12.54(6.93) 12.65(5.49) 5.82(3.54) 4.56(3.58)
[50.97(10.76)]b [48.95(9.00)]b [62.04(18.02)] [68.12(22.21)] [79.08(22.16)] [77.66(18.07)] [81.07(22.05)] [81.43(17.47)] [59.68(11.28)] [55.66(11.70)]
SCIa 31.71(14.82) 29.25(14.66) 39.19(21.31) 44.33(25.52) 63.23(25.80) 61.09(21.05) 65.64(24.85) 63.92(20.41) 41.82(22.48) 37.56(23.72)
[50.63(8.55)]b [49.31(8.55)]b [54.58 (12.17)] [57.43(14.05)] [68.00(14.31)] [66.91(11.72)] [69.31(13.81)] [68.41(11.23)] [56.58(12.63)] [53.82(14.02)]
K-SRS total scorea 34.79(17.21) 31.69(16.44) 55.16(22.88) 63.32(28.49) 75.14(31.81) 72.56(25.93) 78.19(30.78) 76.58(25.23) 50.80(24.52) 55.17(23.20)
[50.88(10.18)]b [49.05(9.72)]b [62.93(13.53)] [67.76(16.85)] [74.75(18.82)] [73.22(15.34)] [76.55(18.21)] [75.60(14.92)] [60.35(14.50)] [62.93(13.72])

Cheon et al./Social responsiveness scale in Korean ASD

a
P < 0.001 significant difference among three samples by Multivariate Analysis of Variance (MANOVA),
b
P < 0.05 between gender groups by one-way ANOVA
c
P < 0.05 between DSM5 ASD and DSM5 SCD by one-way ANOVA
S.D, Standard Deviation; M, male; F, female; DSM IV PDD, Subjects with Pervasive Developmental Disorder diagnosed by DSM IV criteria; DSM5 ASD, Subjects with Autism Spectrum Disorder by
DSM5 criteria; DSM5 SCD, Subjects with Social Communication Disorder by DSM5 criteria; AWA, Social Awareness; COG, Social Cognition; COMM, Social Communication; MOT, Social Motivation; MANN,
Autistic Mannerism; RRBI, Restricted interests & Repetitive Behaviors Index; SCI, Social Communication Index (AWA1COG1COMM1MOT).

INSAR
to complete the questionnaire), the Korean version of were performed using IBM SPSS version 20 (IBM Korea
SRS (K-SRS) was administered to a sample of parents Inc., Seoul, Korea) for Windows.
who visited the clinics (N 5 5). Once this process was
completed and reviewed for adequate performance, the
Results
instrument was released for use in this study. Demographic Characteristics and the K-SRS Scores in Study
ASSQ [Ehlers, Gillberg, & Wing, 1999]: The ASSQ, Samples
composed of 27 items, measures social interaction,
communication problems, restricted and RRB, motor While there were no significant differences in mean age
clumsiness, and associated features. The ability of the among the three study samples, children with ASD were
ASSQ to distinguish autism from other diagnoses is slightly older. Sex distribution in the general sample was
well-established with cutoff scores of 13 for parent rat- even, whereas more males were present in both the clinical
ings and 11 for teacher ratings in European children sample and the epidemiological sample of ASD (Table 1).
[Ehlers et al., 1999].The ASSQ was translated and back- The mean scores for the verbal IQ, the performance IQ and
translated by the investigators, and adequate psycho- the full scale IQ (FSIQ) for the clinical sample and epidemi-
metric properties were demonstrated in Korean children ological ASD sample were 94.4 6 17.4, 93.5 6 17.5, and
from the Korean epidemiological study (n 5 22,660) 92.6 6 17.1, respectively, and 101.1 6 23.8, 95.1 6 22.1,
[Yim, 2012]. Parents from all three study samples com- and 98.2 6 24.4, respectively.
pleted the ASSQ. Mean total raw and T- scores for the K-SRS differed
Cognitive tests: To assess cognitive levels, the significantly in the three study samples. The total scores
Korean-Wechsler Intelligence Scale for Children-III along with all five subscales and two DSM5 subscales
(K-WISC-III) was used for verbal children and Leiter (SCI and RRBI) were highest in the epidemiological ASD
International Performance Scale-Revised was used for sample, followed by the clinical sample; they were low-
those children with difficulty understanding verbal est in the general sample (Table 1). Figure 1 depicts the
instructions. The K-WISC-III and Leiter were used to distributions the T-scores of the K-SRS for each of the
measure cognitive function of the subjects in both the three samples. It shows that the K-SRS scores are nor-
clinical and ASD samples. mally distributed, both in males and females, in the
general sample. The age of the subjects did not influ-
ence the K-SRS scores in the three study samples. Gen-
Statistical Analyses
der affected the scores for social awareness, the
Means and standard deviation (SD) of the K-SRS raw communication subscale, the autistic mannerism
scores and T-scores of five subscales, SCI
(AWA 1 COG 1 COMM 1 MOT) and total scores were
compared among the three study samples using Multi-
variate Analysis of Variance (MANOVA). Internal con-
sistency for the K-SRS total scores was examined by the
item reliability statistics, and Cronbach’s a was calculat-
ed for the three study samples. We also performed cor-
relation analyses between the scores of the K-SRS,
performance IQ, and the ASSQ completed by the
parents in our study samples. After K-SRS norm data
were established in Korean children using the general
population sample (n 5 790), T-score (a standardized Z
score scaled to have a mean of 50 and a standard devia-
tion of 10) [Larsen & Marx, 2011] was computed for the
clinical sample and the epidemiological samples of
ASD. We compared the T-scores from the K-SRS and the
ASSQ (completed by the parents) total scores for chil-
dren with several clinical disorders in the clinical sam-
ple, using one-way Analysis of Variance (ANOVA).
Principal components analysis (PCA) was performed to
examine the factor structure of the autistic trait data.
T-scores and cutoff scores for ASD diagnoses were Figure 1. Distribution of the T-scores of the K-SRS for each of
compared between those from the K-SRS and the SRS to three samples (n 5 1,095) Kernel Density: the local relative fre-
examine cross-cultural comparability. Statistical analyses quency or density of points along the number line of a plot.

INSAR Cheon et al./Social responsiveness scale in Korean ASD 5

Table 2. The Item Reliability Test (Internal Consistency) of the K-SRS in Three Samples
AWA COG COMM MOT MANN (RRBI) SCI K-SRS total
GEN CLI EPI GEN CLI EPI GEN CLI EPI GEN CLI EPI GEN CLI EPI GEN CLI EPI GEN CLI EPI

AWA GEN 1
CLI 1
EPI 1
COG GEN 0.62 1
CLI 0.64 1
EPI 0.58 1
COMM GEN 0.64 0.78 1
CLI 0.71 0.83 1
EPI 0.58 0.76 1
MOT GEN 0.48 0.66 0.70 1
CLI 0.41 0.57 0.70 1
EPI 0.31 0.51 0.65 1
MANN (RRBI) GEN 0.30 0.57 0.63 0.54 1
CLI 0.61 0.78 0.80 0.61 1
EPI 0.44 0.68 0.79 0.60 1
SCI GEN 0.76 0.90 0.94 0.81 0.62 1
CLI 0.76 0.89 0.97 0.78 0.83 1
EPI 0.69 0.87 0.95 0.75 0.79 1
K-SRS total GEN 0.72 0.89 0.94 0.81 0.73 0.99 1
CLI 0.75 0.90 0.96 0.76 0.89 0.99 1
EPI 0.65 0.86 0.95 0.74 0.87 0.99 1
Cronba-ch’s Alpha GEN 0.80 0.76 0.72 0.78 0.79 0.79 0.81
CLI 0.81 0.77 0.71 0.80 0.77 0.80 0.88
EPI 0.81 0.77 0.70 0.79 0.76 0.79 0.86

All items are significant at P < 0.001 by inter-item correlation analysis.

AWA, Social Awareness; COG, Social Cognition; COMM, Social Communication; MOT, Social Motivation; MANN, Autistic Mannerism; RRBI, Restrict-
ed interests & Repetitive Behaviors Index; SCI, Social Communication Index (AWA1COG1COMM1MOT); GEN, General Sample (n 5 790); CLI, Clinical
Sample (n 5 151); EPI, Epidemiological ASD Sample (n 5 154).

subscale and the total score of the K-SRS, in the general the T-scores of the K-SRS in three samples was shown in
sample. In the clinical sample, the social motivation Figure 2. The K-SRS T-score was not correlated with the IQ
subscale of the K-SRS differed significantly by gender. score, except for a minimal negative correlation with the
However, gender did not significantly affect the scores performance IQ (PIQ) score. When the subjects were
of five subscales and the total scores of the K-SRS in the divided into two groups, according to the presence/
epidemiological ASD sample (Table 1). absence of intellectual disability (ID: cutoff IQ 70), mod-
est but significant correlations were detected between
Internal Consistency of the K-SRS
communication, motivation and total scores on the K-SRS
The item reliability ranged from 0.30 to 0.99 in three and PIQ, only in the subjects with ID (Table 3).
samples. Except the MANN-AWA subscales in general
sample, and the MOT-AWA subscales in epidemiologi-
Comparisons of Means for K-SRS T Scores Across Diagnostic
cal ASD sample (0.30 and 0.31), the reliability test
Categories in the Clinical Sample
scored fair to excellent among majority of the K-SRS
items (Table 2). Additionally, Cronbach’s Alphas for the Means of the K-SRS T-scores did not differ significantly by
total items for general, clinical and epidemiological diagnostic categories (ADHD, depressive disorder, anxiety
ASD sample, based on standardized items, were 0.81, disorder and tic disorder) in the clinical sample (n 5 154),
0.88 and 0.86, respectively: those for the subscales of while there were significant differences between the clini-
the K-SRS were demonstrated in Table 2. cal sample, the epidemiological sample of children with
ASD, and the general sample. The mean scores of the K-
Correlation Between the Scores of the K-SRS, IQ and ASSQ
SRS total T-scores in ADHD (n 5 72), depressive disorder
The total score of the ASSQ, completed by the parents, (n 5 10), anxiety disorder (n 5 13), and tic disorder (n 5 14)
was significantly associated with the total T-scores of the were 64.5, 67.2, 64.6, and 57.4, respectively. The K-SRS
K-SRS in the entire study sample. The correlation scatter mean scores for each clinical diagnosis were significantly
plot between the ASSQ scores assessed by the parents and different from the mean score in the epidemiological

6 Cheon et al./Social responsiveness scale in Korean ASD INSAR

Figure 2. Scattering plots of the Correlation between the ASSQ scores and the total T-scores of the K-SRS in three samples
(P < 0.01). ASSQ: Autism spectrum screening questionnaire assessed by parents.

sample of children with ASD (74.5, n 5 151) (P < 0.01, SRS total raw scores were 52 and 48 at T-score of 60 (indi-
comparison by one-way ANOVA). cating clinically significant deficiencies in reciprocal social
behaviors). The K-SRS total raw scores in males and
The Proportion of Confirmed ASD Cases Exceeding Specific
K-SRS T-Score Cutoff in the Epidemiologic ASD Sample females were 79 and 75 at T-score of 76 (strongly associat-
ed with a clinical diagnosis of ASD) (See Supporting Infor-
Among the children who were ASSQ screen positive, mation Appendix 1 & 2). The raw scores in the Korean
the proportion of the confirmed ASD cases (DSM IV population were similar to those for the SRS in the US
PDD and DSM5 ASD) exceeding K-SRS total T-Score population at T-score less than 60; differences appeared in
thresholds at different cut-off points of 55, 60, 65, 70, males at higher T-scores. For example, raw scores in Kore-
75, 80, and 85, by sex, in the epidemiologic sample is an and US males at a T-score of 76 were 79 and 88, respec-
displayed in Table 4. They were 84, 77, 66, 56, 48, 37, tively. Percentages of confirmed ASD diagnoses at a given
and 30%, respectively for males, and 88, 81, 66, 50, 44, raw score cutoff scores were higher for the K-SRS when
28, and 22%, respectively, for females. compared to those in SRS: 92.3 versus 87.9%, respectively
Factor Structure of the K-SRS Data at raw score 55, and 92.3 versus 80.4% at raw score 60.
When K-SRS raw scores in males and females were com-
PCA suggested a one-factor solution for the 1,095 children pared to those from the SRS (70 for males and 65 for
in the general sample, the clinical sample and epidemio- females) they were 64 and 66, respectively. K-SRS raw
logical sample of children with ASD (Table 5.) When 20 scores of 52 in males and 51 in females achieved sensitivi-
items with the factor loadings <0.400 were excluded, the ty and specificity of 0.80 and 0.76, respectively, and 0.92
first component explained 78.1% of variance in the SRS and 0.87, respectively.
scores for the Korean sample, which is consistent with the
original US data, German data for child psychiatric
patients and Japanese data for school children. Discussion
Comparisons of Norm and Cutoff Scores for ASD Diagnoses
This study examined the psychometric properties of the
Between K-SRS and SRS
K-SRS in relation to DSM IV and DSM-5 ASD in a study
K-SRS total raw scores for males and females were 35 and population comprised of three informative samples. We
31, respectively, at K-SRS T-scores of 50 and 52, while K- also examined the relationship between DSM-5 subscales,

INSAR Cheon et al./Social responsiveness scale in Korean ASD 7

Table 3. Correlation Between the IQ and the K-SRS T-Scores in the Clinical and Epidemiological ASD Samples
AWA COG COMM MOT MANN (RRBI) SCI K-SRS total

Total IQ subjects (n 5 266)

FSIQ 0.15 20.00 20.01 0.02 0.02 0.00 20.12
VIQ 0.04 0.00 0.01 0.00 0.03 0.01 20.08
PIQ 20.04 20.09 20.09 20.05 20.06 20.08 20.18a
Subjects > IQ 70 (n 5 241)
FSIQ 0.05 0.05 0.05 0.05 0.07 0.06 20.06
VIQ 0.07 0.06 0.06 0.04 0.08 0.07 20.03
PIQ 0.04 0.03 0.03 0.02 0.05 0.03 20.07
Subjects IQ 70 (n 5 25)
FSIQ 0.02 20.07 20.11 20.11 0.05 20.09 20.15
VIQ 0.03 20.14 20.13 20.16 0.02 20.13 20.20
PIQ 20.27 20.28 20.45a 20.29a 20.22 20.38a 20.42a

a
Correlation is significant at the 0.01 level by Pearson correlation analysis; AWA, Social Awareness; COG, Social Cognition; COMM, Social Communi-
cation; MOT, Social Motivation; MANN, Autistic Mannerism; RRBI, Restricted interests & Repetitive Behaviors Index; SCI, Social Communication Index
(AWA1COG1COMM1MOT); FSIQ, Full-scale IQ; VIQ, Verbal IQ; PIQ, Performance IQ.

Table 4. The Proportion of Confirmed ASD Cases Exceeding epidemiologically-ascertained ASD sample, including the
Specific K-SRS T-Score Cutoff in the Epidemiologic Sample individuals with DSM IV PDD and DSM-5 ASD, followed
by the clinical sample, and then the general sample.
DSM IV PDD DSM5 ASD
(n 5 151) (n 5 133) These findings are consistent with the initial reports on
SRS psychometric properties by the developers [Constan-
K-SRS T-score % of total % of total tino, Przybeck, Friesen, & Todd, 2000]. The validity of K-
Subjects cutoff subjects subjects
SRS was further supported by the significant correlations
Male 55 84.0 87.9 with the total score of the ASSQ, an established ASD
60 76.5 80.4 screening instrument that is used in community and
65 66.4 70.1
70 55.5 58.9
clinical settings in Korea [Yim, 2012] and Europe [Ehlers
75 47.9 51.4 et al., 1999] and the fact that K-SRS means differed across
80 37.0 39.3 children with ASD and children with other forms of
85 30.3 32.7 developmental psychopathology, such as ADHD, depres-
Female 55 87.5 92.3
sive disorder and anxiety disorder. There was a nominally
60 81.3 92.3
65 65.6 73.1 negative correlation between performance IQ (PIQ) and
70 50.0 53.8 the K-SRS among individuals with intellectual disability
75 43.8 46.2 (ID), whereas no correlation was observed among those
80 28.1 30.8
without ID. This supports the notion that the ASD
85 21.9 26.9
Total 55 84.8 88.7 screening capacity for the K-SRS is not likely to be affect-
60 77.5 82.7 ed by the subjects’ intellectual function, especially in
65 66.2 70.7 cognitively intact children with ASD. However, for the K-
70 54.3 57.9
SRS to be recommended as a screener in either clinical
75 47.0 50.4
80 35.1 37.6 practice or research, further work needs to be done to
85 28.5 31.6 develop and test appropriate cutpoints.
Along with the reports from Taiwanese and Japanese
DSM IV PDD, Subjects with Pervasive Developmental Disorder diag-
populations, our findings in Korean children provide
nosed by DSM IV criteria; DSM5 ASD, Subjects with Autism Spectrum
Disorder by DSM 5 criteria. further cross-cultural validation of ASD symptoms.
There have been suggestions in both the lay and scien-
including two subscales, for example, Social Communica- tific communities that the accurate diagnosis and iden-
tion Index (SCI) and Restrictive and Repetitive Behaviors tification of ASD symptoms can be jeopardized by
Index (RRBI), derived from the SRS and clinical diagnosis. cultural biases with respect to the diagnosis of ASD,
The study confirmed the one-factor structure of autistic especially for Asian children, [Kamio et al., 2013; Wang
symptoms and traits as measured by the K-SRS in these et al., 2012]. These conclusions are apparently based on
Korean samples. However, internal consistency and the the untested and unproven assumptions that the pur-
item reliability of the K-SRS were only poor to good in ported deferential attitude of Asian children, such as
the three samples. K-SRS scores were most elevated in the poor eye contact or directed facial expression, cannot

8 Cheon et al./Social responsiveness scale in Korean ASD INSAR

Table 5. PCA of the K-SRS Data
a)
General Sample Clinical Sample Epidemiological
(n 5 790) (n 5 154) ASD sample (n 5 151)
% of Cumulative % of Cumulative % of Cumulative
Components Total variance % Total variance % Total Variance %

1 12.897 19.841 19.841 18.804 28.929 28.929 17.999 27.690 27.690

2 5.812 8.942 28.784 3.526 5.425 34.354 3.594 5.530 33.220
3 2.115 3.254 32.038 2.948 4.536 38.890 2.899 4.460 37.680
4 1.905 2.931 34.969 2.388 3.674 42.564 2.466 3.794 41.474
5 1.677 2.580 37.549 2.291 3.525 46.089 2.274 3.499 44.973

PCA, Principal Component Analysis.

b)
Total combined sample
(n 5 1,095)
Component Total % of variance Cumulative %

1 50.765 78.100 78.100

2 6.676 10.271 88.371
3 1.050 1.615 89.986

ASD, Autism Spectrum Disorders.

be distinguished from symptoms of ASD [Kim, in sub- Surveillance Year 2010 Principal Investigators, 2014;
mission].Therefore, this cross-cultural validation of ASD Kim et al., 2011; Zablotsky, Black, Maenner, Schieve, &
symptoms and ASD assessment tools bears particular Blumberg, 2015], observed discrepancies in the SRS raw
pertinence to the interpretation of increasing preva- scores between Korean and US children may reflect cul-
lence of ASD and integration of the research findings in tural differences in US and Korean parental reporting of
ASD, across various ethnics/racial groups and cultures. their children’s behaviors [Crijnen, Achenbach, & Ver-
The K-SRS norm scores established in this study pro- hulst, 1999]; that is, Korean parents may underreport
vide two interesting findings: (1) A K-SRS raw score at their children’s social problems compared to the
mean T-score (50) was similar to that in SRS in the US parents in the US. It has been hypothesized that Korean
population for both males and females; and (2), K-SRS parents are reluctant to report their children’s behavior
raw scores at higher T-score (79) was lower than that problems due to especially negative societal stigma
(88) on the SRS for males, but not in females [Constan- related to having behavior and emotional problems
tino & Gruber, 2012]. Similar findings have been [Chung et al., 2013]. In addition, such cultural differ-
reported in cross-cultural comparison studies that ences in the parental reports were more prominent in
included the assessment of children’s behavior prob- boys than in girls in our study: such gender differences
lems. In a study using the ADHD Rating Scale (ARS) in have been reported in other Asian cultures [Chao &
Korean children, the raw scores from the Korean Teach- Tseng, 2002]. In order to minimize such sex-based cul-
er reports on the ARS, in a general sample, were lower tural bias in identifying behavioral/social difficulties in
than those reported for American children [Kim et al., children, use of sex-based standardized cut-off scores
2003]. In a multi-cultural comparison study of the (such as sex-based T score), rather than raw cut-off
CBCL in preschool children, mean Total Problem Scores scores is recommended across different cultures.
for Korean children ranked 4th from the bottom among The K-SRS data indicate rather low specificity to dis-
24 countries and lowest for DSM-IV Oppositional Defi- tinguish individuals with SCD from those with other
ant Disorder [Rescorla et al., 2011]. Other studies have child psychiatric conditions, whereas it is useful to dis-
reported that Korean parents report fewer problems in tinguish them from typically developing children. This
their offspring on the CBCL-internalizing and external- may partially result from the way SCD diagnoses were
izing behavior scales than do parents from the US made for the clinical sample; they were based on clini-
[Chung et al., 2013]or Australia [Oh, Shin, Moon, Hud- cal diagnoses rather than using semistructured or struc-
son, & Rapee, 2002]. Since there is no evidence of prev- tured diagnostic interviews. The usefulness of the SRS
alence differences between US and South Korea [Autism for differentiating SCD from other child psychiatric dis-
and Developmental Disabilities Monitoring Network orders warrants further investigation.

INSAR Cheon et al./Social responsiveness scale in Korean ASD 9

 Finally, the strong correlation between SCI and RRBI of Health &Welfare, South Korea (HI12C0021-A120029,
of K-SRS in all three study samples raises questions HI12C0245-A120296). This work was also supported in part
about the independence of ASD and SCD as diagnostic by U.S. NIH/NICHD grant # P30 HD062171 to Dr. Constan-
entities. Further research with larger numbers of sub- tino, the Intellectual and Developmental Disabilities
jects will help clarify whether SCD patients are unique- Research Center at Washington University
ly distinguished by dissociation between SCI and RRB
symptoms that are otherwise highly correlated in
Disclosure
children.
Study limitations include: Test–retest stability and
Dr. Constantino receives royalties from Western Psy-
inter-rater reliability of the K-SRS were not measured in
chological Services for the commercial distribution of
this study. Second, the number of the subjects for SCD
the Social Responsiveness Scale.
diagnoses was very small. Third, the low response rate in
the general sample could be a source for bias in estab-
lishing K-SRS norms. While we do not have further data References
for nonparticipants in the general sample, we have
APA. (1994). Diagnostic and statistical manual of mental disor-
access to additional SRS parental survey data ascertained der (4th ed.). Washington, DC: APA Press.
from a later, independent cohort of children from Autism and Developmental Disabilities Monitoring Network
another geographic area in South Korea (N 5 4,811, 1st Surveillance Year 2010 Principal Investigators. (2014). Prev-
and 4th graders of all elementary schools in a city in alence of autism spectrum disorder among children aged
southern western peninsula of South Korea) [Personal 8 years - Autism and developmental disabilities monitoring
communication]. The mean (31) and SD (15) in this network, 11 sites, United States, 2010. Morbidity and Mor-
independent cohort were similar to those in our general tality Weekly Report. Surveillance Summaries, 63, 1–21.
sample. Such consistency suggests that the low participa- Bolte, S., Poustka, F., & Constantino, J.N. (2008). Assessing
autistic traits: cross-cultural validation of the social respon-
tion rate in the general sample may have not biased the
siveness scale (SRS). Autism Research, 1, 354–363. doi:
K-SRS norm data established in the present study. Final-
10.1002/aur.49.
ly, the lack of gender effects on the K-SRS in epidemio-
Chao, R., & Tseng, V. (2002). Parenting of Asians (2nd ed.).
logical sample of ASD children in the present study Mahwah, New Jersey: Lawrence Erlbaum Associates.
appears to stem from lack of statistical power due to the Charman, T., Baird, G., Simonoff, E., Loucas, T., Chandler, S.,
uneven distribution of genders in this sample. et al. (2007). Efficacy of three screening instruments in the
To the best of our knowledge, the present study is identification of autistic-spectrum disorders. The British
the first to examine the relationship between DSM-5 Journal of Psychiatry, 191, 554–559. doi:10.1192/bjp.bp.
subscales, including SCI and RRBI, derived from the SRS 107.040196
and DSM IV and DSM-5 ASD diagnosis using an epide- Chung, K.M., Ebesutani, C., Bang, H.M., Kim, J., Chorpita,
miologic sample. In addition, this study is the first B.F., Weisz, J.R. (2013). Parenting stress and child behavior
problems among clinic-referred youth: Cross-cultural differ-
study to examine the psychometric properties of the
ences across the US and Korea. Child Psychiatry and
SRS in Korean children.
Human Development, 44, 460–468. doi:10.1007/s10578-
012-0340-z
Conclusions Constantino, J.N., Davis, S.A., Todd, R.D., Schindler, M.K.,
Gross, M.M., Brophy, S.L. (2003a). Validation of a brief
quantitative measure of autistic traits: Comparison of the
The SRS Korean version had adequate reliability and
social responsiveness scale with the autism diagnostic inter-
validity for measuring ASD symptoms in Korean sub-
view-revised. Journal of Autism and Developmental Disor-
jects. Our findings suggest that the K-SRS may also be ders, 33, 427–433.
useful as a screening tool for DSM IV PDD and DSM 5 Constantino, J.N., & Gruber, C.P. (2005). The Social Respon-
ASD in Korean children but further work needs to be siveness ScaleTM. Torrance, CA: Western Psychological
done to develop and test appropriate cutpoints. Services.
Constantino, J.N., & Gruber, C.P. (2012). The Social Respon-
Acknowledgment siveness ScaleTM Second Edition (SRSTM-2). Torrance, CA:
Western Psychological Services.
The authors are grateful to all of the schools and families
Constantino, J.N., Gruber, C.P., Davis, S., Hayes, S.,
participated in the study. This research was funded by a
Passanante, N., Przybeck, T. (2004). The factor structure of
Simons Foundation Autism Research Initiative Pilot Grant autistic traits. Journal of Child Psychology and Psychiatry,
(137032 M134793), Autism Speaks Pilot Research Grant, and Allied Disciplines, 45, 719–726. doi:10.1111/j.1469-
Brain Research Foundation Research Grant, NIMH Career 7610.2004.00266.xJCPP266[pii]
Awards (K01MH079317), NIEHS R01 Award (R01 ES021462- Constantino, J.N., Hudziak, J.J., & Todd, R.D. (2003b). Deficits
01) and Korean Health Technology R&D Project, Ministry in reciprocal social behavior in male twins: Evidence for a

10 Cheon et al./Social responsiveness scale in Korean ASD INSAR

 genetically independent domain of psychopathology. Jour- 5, DSM-IV, and checklist for autism spectrum disorder.
nal of the American Academy of Child and Adolescent Psy- Research in Autism Spectrum Disorders, 7, 298–306. doi:
chiatry, 42, 458–467. doi:10.1097/01.CHI.0000046811. http://dx.doi.org/10.1016/j.rasd.2012.08.011
95464.21S0890-8567(09)60918-7[pii] Mayes, S.D., Calhoun, S.L., Murray, M.J., Pearl, A., Black, A.,
Constantino, J.N., Przybeck, T., Friesen, D., & Todd, R.D. Tierney, Cheryl D. (2014). Final DSM-5 under-identifies
(2000). Reciprocal social behavior in children with and mild autism spectrum disorder: Agreement between the
without pervasive developmental disorders. Journal of
DSM-5, CARS, CASD, and clinical diagnoses. Research in
Developmental and Behavioral Pediatrics, 21, 2–11.
Autism Spectrum Disorders, 8, 68–73. doi:http://dx.doi.org/
Crijnen, A.A., Achenbach, T.M., & Verhulst, F.C. (1999). Prob-
10.1016/j.rasd.2013.11.002
lems reported by parents of children in multiple cultures:
The Child Behavior Checklist syndrome constructs. The Oh, K.J., Shin, Y.J., Moon, K.J., Hudson, J.L., & Rapee, R.M.
American Journal of Psychiatry, 156, 569–574. doi:10.1176/ (2002). Child-rearing practices and psychological disorders
ajp.156.4.569 in children: Cross-cultural comparison of Korea and Austra-
Duvekot, J., van der Ende, J., Verhulst, F.C., & Greaves-Lord, K. lia. Yonsei Medical Journal, 43, 411–419. doi:10.3349/
(2015). The screening accuracy of the parent and Teacher- ymj.2002.43.4.411
Reported Social Responsiveness Scale (SRS): Comparison Rescorla, L.A., Achenbach, T.M., Ivanova, M.Y., Harder, V.S.,
with the 3Di and ADOS. Journal of Autism and Develop- Otten, L., Bilenberg, N. (2011). International comparisons
mental Disorders, 45, 1658–1672. doi:10.1007/s10803-014- of behavioral and emotional problems in preschool chil-
2323-3 dren: parents’ reports from 24 societies. Journal of Clinical
Ehlers, S., Gillberg, C., & Wing, L. (1999). A screening ques- Child and Adolescent Psychology, 40, 456–467. doi:
tionnaire for Asperger syndrome and other high- 10.1080/15374416.2011.563472
functioning autism spectrum disorders in school age chil-
Reynolds, C.R., & Kamphaus, R.W. (2004). Behavior assessment
dren. Journal of Autism and Developmental Disorders, 29,
system for children (BASC) (2nd ed.). Circle Pines, MN:
129–141.
American Guidance Service.
Gerhard, T. (2008). Bias: Considerations for research practice.
American Journal of Health-System Pharmacy, 65, 10. Wang, J., Lee, L.C., Chen, Y.S., & Hsu, J.W. (2012). Assessing
Kamio, Y., Inada, N., Moriwaki, A., Kuroda, M., Koyama, T., autistic traits in a Taiwan preschool population: Cross-
Tsujii, H. (2013). Quantitative autistic traits ascertained in a cultural validation of the Social Responsiveness Scale (SRS).
national survey of 22 529 Japanese school children. Acta Journal of Autism and Developmental Disorders, 42, 2450–
Psychiatrica Scandinavica, 128, 45–53. doi:10.1111/acps. 2459. doi:10.1007/s10803-012-1499-7
12034 Wigham, S., McConachie, H., Tandos, J., Le Couteur, A.S., &
Kim, S.H., Kim, Y.S., Koh, Y.J., Lim, E., Kim, S., & Leventha, Gateshead Millennium Study core team. (2012). The reli-
B.L. (2016). Often Asked but Rarely Answered: Can Asians ability and validity of the Social Responsiveness Scale in a
meet DSM-5/ICD-10 Autism Spectrum Disorder Criteria? UK general child population. Research in Developmental
Journal of Child and Adolescent Psychopharmacology. Disabilities, 33, 944–950. doi:10.1016/j.ridd.2011.12.017
(ahead of print) doi:10.1089/cap.2016.0021.
Yim, G. (2012). Validation of the Autism Spectrum Screening
Kim, Y.S., Leventhal, B.L., Koh, Y.J., Fombonne, E., Laska, E.,
Questionnaire (ASSQ) in a school-aged population in Korea
Lim, E.C. (2011). Prevalence of autism spectrum disorders
public health. Yale Univeristy.
in a total population sample. The American Journal of Psy-
chiatry, 168, 904–912. doi:appi.ajp.2011.10101532[- Zablotsky, B., Black, L.I., Maenner, M.J., Schieve, L.A., &
pii]10.1176/appi.ajp.2011.10101532 Blumberg, S.J. (2015). Estimated prevalence of autism and
Kim, Y.S., So, Y.K., Noh, J.S., Choi, N.K., Kim, S.J., Koh, Y.J. other developmental disabilities following questionnaire
(2003). Normative data on the Korean ADHD Rating Scales changes in the 2014 National Health Interview Survey.
(K-ARS) for parents and teacher. Journal of Korean Neuro- National Health Statistics Reports, 3, 1–20.
psychiatric Association, 42, 352–359.
Larsen, R.J., & Marx, M.L. (2011). An introduction to mathe-
matical statistics and its applications, Pearson (5th ed.).
Supporting Information
Maenner, M.J., Rice, C.E., Arneson, C.L., Cunniff, C., Schieve,
L.A., Carpenter, L.A. (2014). Potential impact of DSM-5 cri- Additional Supporting Information may be found in the
teria on autism spectrum disorder prevalence estimates.
online version of this article at the publisher’s web-site:
JAMA Psychiatry, 71, 292–300. doi:1814891[pii]10.1001/
jamapsychiatry. 2013.3893 Appendix 1. The SRS Korean T-score norms for males.
Mayes, S.D., Black, A., & Tierney, C.D. (2013). DSM-5 under- Appendix 2. The SRS Korean T-score norms for
identifies PDDNOS: Diagnostic agreement between the DSM- females.

INSAR Cheon et al./Social responsiveness scale in Korean ASD 11