Psychiatry Research 230 (2015) 255261

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Validity and reliability analysis of the Chinese parent version of the

Autism Spectrum Rating Scale (618 years)
Hao Zhou a, Lili Zhang a, Lijie Wu b, Xiaobing Zou c, Xuerong Luo d, Kun Xia e, Yimin Wang a,
Xiu Xu f, Xiaoling Ge g, Caihong Sun b, Hongzhu Deng c, Eric Fombonne h, Yong-Hui Jiang i,
Weili Yan j,n, Yi Wang a,nn
a
No. 399, Wanyuan Road, Minhang District, Division of Neurology, Children's Hospital of Fudan University, Shanghai, China
b
School of Public Health, Harbin Medical University, Harbin, China
c
Child Development Center, The Third Afliated Hospital, Sun Yat-Sen University, Guangzhou, China
d
Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
e
State Key Laboratory of Medical Genetics, Changsha, China
f
Department of Child Healthcare, Children's Hospital of Fudan University, Shanghai, China
g
Childrens Hospital of Fudan University, Shanghai, China
h
Oregon Health & Science University, Portland, OR, USA
i
Division of Medical Genetics, Department of Pediatrics and Neurobiology, Duke University School of Medicine, USA
j
Department of Clinical Epidemiology, Children's Hospital of Fudan University, Shanghai, China

art ic l e i nf o a b s t r a c t

Article history: This study aimed to investigate the validity and reliability of the Chinese parent version of the Autism
Received 24 February 2015 Spectrum Rating Scale (ASRS, 618 years) for a general sample of Chinese children. The study involved
Received in revised form assessing 1625 community-based subjects aged 612 years from four sites (Shanghai, Guangzhou,
31 August 2015
Changsha, and Harbin city) in China and 211 clinic-based participants aged 618 with a conrmed di-
Accepted 3 September 2015
agnosis of autism spectrum disorders (ASDs). The internal consistency (Cronbachs alpha) ranged from
Available online 8 September 2015
0.585 to 0.929, and the testretest reliability (interclass correlations) ranged from 0.542 to 0.749, in-
Keywords: dicating no signicant difference between the two tests at an interval of 24 weeks. The construct va-
Epidemiology lidity was relatively excellent, and the concurrent validity with the Social Responsiveness Scale (SRS)
Autism
(Pearson correlations) was 0.732 between the two total scores. Receiver operating characteristics (ROC)
Screening
analyses showed excellent and comparable discriminant validity of the ASRS with respect to the SRS,
Scale
Validation with an area under the curve (AUC) of 0.9507 (95% CI: 0.930.97) versus 0.9703 (95% CI: 0.960.98),
Child respectively. Our data suggested a cutoff Z60 for the Chinese version of the ASRS, with good accuracy in
screening autism symptoms (sensitivity 94.2%, specicity 77%). The Chinese parent version of the
ASRS is therefore a reliable and valid tool for screening autistic symptoms in Chinese children in general.
& 2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Autism spectrum disorders (ASDs) are a group of neurodeve-
lopment disorders characterized by diverse clinical phenotypes
and varying levels of impairment in social interaction and re-
ciprocal communication, as well as restricted and repetitive in-
terests and behaviors (Wills, 2014). The term ASDs is an um-
brella term in the DSM-V. Symptoms are typically notable before
n
Correspondence to: No. 399, Wanyuan Road, Minhang District, Division of
Neurology, Children's Hospital of Fudan University, Shanghai, China.
Fax: 86 21 64931901.
nn
Corresponding author. Fax: 86 21 64931901
E-mail addresses: yanwl@fudan.edu.cn (W. Yan),
yiwang@shmu.edu.cn (Y. Wang).
the age of 3 years old, and numerous studies have indicated a high
level of functional limitations and poor life quality in affected
children (Eaves and Ho, 2008; Barneveld et al., 2014). The disease
burden of ASD for families and society is remarkable (Horlin et al.,
2014). ASD is one of the fastest-growing disorders worldwide,
with many countries showing signicantly increased incidence in
recent decades (Williams et al., 2006; Elsabbagh et al., 2012;
Blumberg et al., 2013). Increased public awareness of ASDs has
recently resulted in more scientic epidemiological surveys of
ASDs in many areas (Idring et al., 2014; Ouellette-Kuntz et al.,
2014; Zahorodny et al., 2014).
To conduct a national epidemiology survey of ASDs in any
population, the usual method is to screen a representative sample
of children to identify those who may have ASDs and conduct
further clinical assessment with more in-depth approaches to

http://dx.doi.org/10.1016/j.psychres.2015.09.003
0165-1781/& 2015 Elsevier Ireland Ltd. All rights reserved.
256 H. Zhou et al. / Psychiatry Research 230 (2015) 255261
derive unbiased prevalence estimations. A questionnaire-based
screening is an ideal approach for conducting ASD screening be-
cause of the easy administration and use. In recent decades, the
epidemiology of autism in children has made great progress in the
development of valid and reliable screening instruments for di-
verse participants, such as the Checklist for Autism in Toddlers
(CHAT), the Modied Checklist for Autism in Toddlers (M-CHAT),
and the Checklist for Autism in Toddler-23 (CHAT-23) re-
commended for use in very young children (Robins et al., 2014).
The Pervasive Developmental Disorders Screening Test (PDDST) is
a 40-item scale that can also be used for children from birth to
3 years old (Ferreri, 2014). The Social Communication Ques-
tionnaire (SCQ) is a 40-item scale derived from a diagnostic tool
(ADI-R) for use with children ages 4 years and older (Mulligan
et al., 2009). The Social Responsiveness Scale (SRS) is a 65-item
scale for children ages 418 years (Wigham et al., 2012). These
screening instruments are usually completed within 1020 min
and are designed to estimate the risk of autistic condition. How-
ever, reviews of autism epidemiological studies have indicated
that screening instruments have been very heterogeneous in po-
pulation surveys (Matson et al., 2007). Such studies have rarely
been based on the use of criterion instruments of known reliability
and validity applied to representative samples in the general po-
pulation. In a way, the variability in questionnaires reects dif-
ferences in the culture and representative samples of the surveyed
areas. Besides, the lack of properly validated and reliable instru-
ments to screen for autistic behaviors in the general population
has been a signicant barrier to epidemiologic studies of these
conditions.
Research on ASDs has only recently begun in China, and the
exact national prevalence of ASDs in China remains unknown (Li
et al., 2011). One year ago, an important initiative program funded
by the Ministry of Health was launched to boost autism awareness
among clinical experts and researchers. As part of this program, a
national epidemiological survey of ASD among the school-aged
(612 years) population of China was designed. To conduct the
screening phase of this survey, an instrument that is properly
validated for the Chinese population is necessary.
Currently, there is no published autism screening tool that has
been developed in Chinese. Several English versions of autism
screening tools have been adapted to Chinese. For example, the
Chinese version of the CHAT-23, which is designed for use in
primary care settings at the 18-month visit, combines 23 items
from parental reports with 2 items from the direct observation of
the child. The CHAT-23 has excellent screening performance in
representative Hong Kong samples (Wong et al., 2004). A Man-
darin Chinese version of the CAST (M-CAST) was translated and
developed by Dr. Sun Xiang, and it has good psychometric prop-
erties for Chinese children aged 411 years (Sun et al., 2014).
Moreover, the Chinese version of the Social Responsiveness Scale
(SRS) and the Social Communication Questionnaire (SCQ) were
shown to have good reliability and validity in Taiwanese children
(Gau et al., 2011, 2013). However, those existing Chinese versions
of screening instruments were applied in populations that either
lacked regional diversity or were not matched to the age range of
our studied population. Therefore, it is necessary to develop a
screening tool appropriate for the age range and population
diversity of this national ASD prevalence survey.
Among recently developed instruments designed to detect
autistic symptomatology in both clinical and nonclinical samples,
we specially considered the Autism Spectrum Rating Scale (ASRS)
(Goldstein and Naglieri, 2009) for evaluation. The ASRS was de-
signed for both young children aged 25 years and children aged
618 years, and it has excellent reliability and validity in the U.S.
population. This scale has both full-length and short versions, with
the former comprising 70/71 items and the latter containing 15
items. Separate forms are completed by parents (ASRS Parent
Rating) or teachers (ASRS Teacher Rating). Both have the same
items and structure. The full-length ASRS was designed not only as
an screening tool to guide diagnostic decisions but also as a tool
for treatment planning based on ongoing monitoring of the re-
sponse to intervention and evaluation; by contrast, the short ver-
sion is suitable only for screening. Comparisons with other in-
struments are easy because of the availability of standard scores.
Therefore, according to the task of the epidemiologic surveys and
further ongoing monitoring for ASD children, we evaluated the
full-length ASRS (618 years) as the candidate screening tool for
the national epidemiological survey, with the following aims:
(1) to examine the psychometric properties of the Chinese parent
version of the ASRS in a Chinese sample aged 612 years and (2) to
measure the discriminant validity of the Chinese parent version of
the ASRS as a screening instrument for investigate the national
prevalence of ASDs.
2. Methods
2.1. Study populations
2.1.1. General sample
The ASRS was developed for the general population in the U.S.
(Goldstein and Naglieri, 2009). Thus, we selected the community-
based population (aged 612 years) as the general sample to en-
sure its representativeness by using convenient cluster sampling.
Four community-based samples were selected in Shanghai, Har-
bin, Guangzhou, and Changsha. All children with local residency or
children who have been living in the community for more than six
months were eligible to participate in this study, with a total
number of 2053.
2.1.2. Clinically diagnosed ASD cases
To analyze concurrent and discriminant validity, children who
had been clinically diagnosed with ASDs were recruited from the
local autism rehabilitation center. The clinical diagnosis of ASD
was made by senior child psychiatrists who have extensive clinical
and research experience in the assessment and treatment of
children with ASD according to DSM-V criteria, conrmed using
the autism diagnostic interview-revised (ADI-R). In total, 211 ASD
cases aged 618 years were recruited.
2.2. Measures
2.2.1. ASRS Chinese parent version
The Chinese parent version of the full-length ASRS (618 years)
was used in this study. The ASRS questionnaire evaluates the fre-
quency of each behavior (0 for never and 4 for Very Frequently)
to quantify autistic features. According to different study purposes,
the ASRS (for children 618 years old) can be referred to as the
ASRS scales, DSM-IV-TR scales, and treatment scales. A three-fac-
tor solution was the most suitable parent version of the ASRS
scales for the 618 age group. Three factors constituting 60 of the
total 71 items are generated for screening: one factor related to
Social/Communication (19 items); another factor with items re-
lated to Unusual behaviors (24 items); and the third factor Self-
Regulation (17 items) that included items primarily related to at-
tention problems, impulsivity, and compliance. These 3 scales are
combined into a single composite score, the T-score, which was
developed for screening purposes. High scores on the ASRS scales
suggest that additional evaluation is required. The DSM-IV-TR
scale is derived from 34 items based on experience from the total
71 items, some of which also contribute to the diagnosis scales.
Finally, the treatment scales consist of 8 subscales that can be used
 H. Zhou et al. / Psychiatry Research 230 (2015) 255261
to monitor treatment responses: Peer Socialization (9 items, PS),
Adult Socialization (6 items, AS), Social/Emotional Reciprocity (13
items, SER), Atypical Language (6 items, AL), Stereotypy (5 items,
ST), Behavioral Rigidity (8 items, BR), Sensory Sensitivity (6 items,
SS), and Attention (11 items, AT). This scale can be used as an
ongoing tool for monitoring the clinical assessment of children
with ASD. All original scales are set to the T-score metric, which
has a normative mean of 50 and a standard deviation of 10. The
ASRS has good inter-rater reliability, testretest reliability, con-
struct validity, and content validity (Goldstein and Naglieri, 2009).
In view of our research purpose, the study primarily focuses on the
ASRS scales. The Chinese version of the ASRS was developed by the
team of the Research Special Fund for the Public Welfare Industry
of Health of China using standard translation and back-translation
procedures (Harkness and Schoua-Glusberg, 1998) with permis-
sion from Goldstein and Naglieri and approval from the Multi-
Health System. The Chinese ASRS was initially piloted with a small
sample containing ve Chinese parents whose children were 612
years old; they were selected from a local autism rehabilitation
center in Shanghai. We retained all 71 items that were translated
using culturally equivalent expressions in the Chinese environ-
ment for further practice.
2.2.2. Social responsiveness scale (SRS) as the criterion instrument
The SRS was designed to quantify autistic behaviors. It com-
prises 65 items that are scored to measure the severity (mild to
severe) and frequency (0 for never true and 3 for always true) of
each behavior, resulting in a total score and ve subscale scores
(i.e., social awareness, social cognition, social communication, so-
cial motivation, and autistic mannerisms). The survey can be
completed by parents, caregivers, or teachers in 1520 minutes.
The SRS has been used in a variety of studies described elsewhere
(Constantino and Gruber, 2002).
Different versions of the SRS have been shown to have good
psychometric properties (Blte et al., 2008; Fombonne et al.,
2012). The Chinese SRS has demonstrated good reliability and
validity with regard to internal consistency, testretest reliability,
concurrent validity with ADI-R, and discriminant validity (Gau
et al., 2013). Because of these advantages, we used the Chinese
version of the SRS as the criterion instrument to establish the
concurrent and discriminant validity of the ASRS in this study
(Umphress et al., 1997; Howard and Hughes, 2012).
2.3. Protocol
Parents of children in both the community and local autism
rehabilitation centers were informed of the details of this study by
the local authority and were then invited to participate in the
study. The parents who consented were then asked to complete
the parent version of ASRS questionnaire at home. Parents of
children with ASD were asked to complete the ASRS and SRS
questionnaires while receiving the ADI-R interview at the hospital.
In total, we received 1684 returned ASRS questionnaires from the
community, with a response rate of 83.97%. The study was ap-
proved by the Ethics Review Board of the Childrens Hospital of
Fudan University ([2012] No.185).
2.4. Data analysis
The data analysis was conducted by statisticians using the Stata
statistical package program (version 11.0, College Station, Texas
77845, United States). We performed a conrmatory factor ana-
lysis (CFA) by using the three-factor structural model (60 items)
based on an exploratory factor analysis (EFA) of the technical
manual of ASRS scales (Harrington, 2008). Several model-tting
indices were employed as structural parameters: the goodness-of-
257
t index (GFI), the adjusted goodness-of-t index (AGFI), the
comparative t index (CFI), the non-normed t index (NNFI), and
the root mean square error of approximation (RMSEA). The test
retest reliability was evaluated using the intra-class correlations
and paired t-tests (n 131) (Brown et al., 2004). The internal
consistency of each subscale was tested by using the Cronbachs
alpha (n 1625), and the concurrent validity of the SRS (n 211)
was tested using the Pearson correlation coefcient (Sen, 1993). To
measure the discriminant validity, we compared the mean scores
of the Chinese ASRS between the clinical sample aged 612 years
(n 190) and the community-based sample (n 1625) by using
Students t-test. Between-group differences (effect size) were
analyzed using Cohens d (Larner, 2014). Age and gender effects on
the subscale scores and T-scores were analyzed by using multiple
linear regressions. Receiver operating characteristic (ROC) analysis
was conducted, and the area under the curve (AUC) and 95%
condence interval (CI) were computed to evaluate the overall
discriminant validity of the Chinese parent version of the ASRS
and compared with the original SRS. All tests were two-tailed, and
a p-value of 0.05 was retained as the level of statistical
signicance.
3. Results
3.1. Demographic characteristics of the participants
Of the 2053 children eligible for the general sample, 1684
(83.97%) were contacted and given questionnaires to complete.
After the exclusion of questionnaires because of various errors,
1625 participants (mean age: 8.85 71.78 years) including 830 boys
(51.1%) were included in the analysis. We randomly selected 131
participants (approximately 10% of the total sample) to complete
the same questionnaire again at an interval of 24 weeks to
measure testretest reliability. Of the 211 children aged 618 years
with ASDs (8.9 71.7 years) who were recruited from the local
autism rehabilitation center, 87.7% were male (the male-to-female
ratio was 7.8:1). The ADI-R interview results are consistent with
clinical diagnosis.
3.2. Chinese version of the ASRS scale scores
A preliminary analysis of the general sample obtained with the
parent version of the ASRS was performed. Boys in the commu-
nity-based sample had signicantly higher T-standardized scoring
in the areas of Social Communication (SC), Unusual Behavior (UB),
and Self-Regulation (SR), and in their standardized total score (T-
score) by a difference of 23 points relative to the scores for girls,
Pso0.001 (Fig. 1). Fig. 2 shows slight site differences among cities
for the SC, UB, SR and T-scores. Minor age effects on the ASRS
Fig. 1. Slight difference between males and females for SC (Social Communication),
UB (Unusual Behaviors), SR (Self-Regulation), and T-score (Total score).
258 H. Zhou et al. / Psychiatry Research 230 (2015) 255261

Table 2
Internal consistency of the Chinese parent version of the ASRS (n 1625).

Scales Number of items Cronbachs alpha

T-score 60 0.91
ASRS scales SC 19 0.88
UB 24 0.84
SR 17 0.85
DSM-IV-TR scale 34 0.85
Treatment scales PS 9 0.69
AS 6 0.64
SER 13 0.81
AL 6 0.69
ST 5 0.59
BR 8 0.68
SS 6 0.62
Fig. 2. Slight site difference among cities for SC (Social Communication), UB AT 11 0.80
(Unusual Behaviors), SR (Self-Regulation), and T-score (Total score).
SC, Social/Communication; UB, Unusual Behaviors; SR, Self-Regulation; PS, Peer
Socialization; AS, Adult Socialization; SER, Social/Emotional Reciprocity; AL, Aty-
Table 1 pical Language; ST, Stereotypy; BR, Behavioral Rigidity; SS, Sensory Sensitivity; AT,
Gender differences for ASRS scale scores in clinical cases. Attention; T-score, Total Score.

ASRS scales Clinical case t P

analysis. We initially conducted conrmatory factor analysis based
Male (n 184) Female (n 27) on the EFA results of the original ASRS (60 items). In the CFA
modeling, the RMSEA value was 0.043 (o0.05). We obtained the
SC 45.9 7 12.14 50.117 10.22  1.9 0.065 values of 0.818 for CFI, 0.856 for GFI, 0.844 for AGFI, and 0.767 for
UB 44.107 13.77 43.88 7 10.75 0.093 0.926
NNFI, all of which were acceptable. The CFI, GFI, AGFI, NNFI, and
SR 34.26 7 10.18 38.127 8.71  2.06 0.046*
T-score 68.977 6.39 71.46 7 4.42  2.53 0.015* RMSEA values indicated a relatively good model t. The results
showed that the Chinese ASRS parent version has relatively good
SC, Social/Communication; UB, Unusual Behaviors; SR, Self-Regulation; T-score, construct validity.
Total Score. Data are represented by the mean and standard deviation.
*
Po 0.001.
3.6. Concurrent validity

scales scores were found for boys and girls (r  0.010.07).
Among the cases, girls had higher scores than the boys did, with
mean differences of 0.4 SD for SC, 0.4 SD for UB, and 0.3 SD for the
T-score (Table 1).
3.3. Item reliability
The screening scales had high Cronbachs alpha values (i.e.,
Social/Communication 0.880, Unusual Behaviors 0.841, Self-Reg-
ulation 0.851, and T-score 0.910). The Cronbachs alpha of the
DSM-IV-TR scale was 0.854. There were eight treatment subscales
with Cronbachs alpha values ranging from 0.58 (ST) to 0.81 (SER).
These subscales were involved in treatment evaluation. Notably,
the treatment subscales had 9 items or fewer, which probably
explains the lower range of alpha coefcients. All subscales with
alpha values 40.80 had a higher number of items (11 items or
more) (see Table 2).
3.4. Testretest reliability
Two to four weeks after the initial questionnaire administra-
tion, we asked 131 randomly selected community participants
(approximately 10% of the total sample) to repeat the Chinese
parent version of the ASRS. Only the scoring of UB, AL, and ST
showed statistically signicant difference between the two tests at
an interval of 24 weeks; the others showed no statistically sig-
nicant difference. However, Table 2 shows that the Chinese ASRS
had good intra-class correlations (ICC 0.5420.749), which in-
dicate that the stability of this questionnaire is acceptable over
time (Table 3).
3.5. Construct validity
The KaiserMeyerOlkin (KMO) measure (0.945) and Bartletts
test (0.000) demonstrated that the data were suitable for factor
To test for concurrent validity, we used the SRS as the external
criterion and estimated its correlation with the ASRS in the clinical
sample. The results for the correlations between the subscales and
the total scores of the ASRS scales as well as the SRS are shown in
Table 4. The high correlation between the total scores (r 0.732) of
the two scales shows that the 2 questionnaires are robust and
comparable in measuring autistic symptomatology. However,
some subscales of the two instruments had weak correlations,
such as the UB and social awareness subscales, for which the
correlation index was 0.152.
3.7. Discriminant validity
To measure the discriminant ability of the ASRS, we compared
the scores for the ASRS scales from the community-based parti-
cipants (n 1625) with those for the clinic cases (n 190) within
the same age range (612 years old). Multiple linear regressions
showed a slight age effect (b  0.05 for the general sample,
b0.12 for clinical cases, Ps 0.260, 0.070) and a gender effect on
the T-score (b  0.13 for the general sample, b0.09 for clinical
cases, Ps 0.000, 0.224). There were signicant differences be-
tween the two groups in the two ASRS subscale scores (Table 5).
The clinical sample showed signicantly higher T-scores and SC,
UB and SR scores compared with the general sample (Cohens d
from 1.14 to 2.27).
The ROC analysis is shown in Fig. 3. Both versions with an AUC
over 0.9 indicated equally excellent discriminant validity in the
screening of ASD cases, with the AUC of the total scores equaling
0.9507 (95% CI: 0.930.97) versus 0.9703 (95% CI: 0.960.98) for
the ASRS and SRS, respectively. We further performed the same
analysis separately in both genders, and the results indicated even
better performance for girls (AUC0.9958; 95% CI: 0.99141.0000)
on the ASRS. According to the approach that maximizes the sum of
sensitivity and specicity, our data suggested a cutoff T scoreZ60
for the ASRS to achieve a sensitivity of 94.2% and a specicity of
 H. Zhou et al. / Psychiatry Research 230 (2015) 255261 259

Table 3
Testretest reliability of the Chinese parent version of the ASRS.

Scales Test-retest reliability (n=131)

ICC 95%CI Initial Re-test p r

T-Score 0.739 0.630.81 57.696.22 56.976.98 0.174 0.591*

ASRS Scales SC 0.702 0.580.79 59.459.66 59.6710.09 0.790 0.539*
UB 0.669 0.530.77 59.935.41 58.506.48 0.006 0.530*
SR 0.691 0.560.78 50.657.43 49.907.83 0.255 0.529*
DSM-IV-TR Scale 0.749 0.650.82 59.325.60 58.786.12 0.239 0.603*
Treatment Scales PS 0.611 0.450.72 54.709.09 54.389.37 0.709 0.438*
AS 0.705 0.580.78 52.577.93 51.798.34 0.248 0.546*
SER 0.716 0.600.80 58.608.58 58.499.45 0.878 0.558*
AL 0.597 0.430.72 56.807.32 55.217.78 0.025 0.439*
ST 0.542 0.350.68 57.506.24 55.976.50 0.014 0.389*
BR 0.673 0.540.77 58.346.71 57.377.19 0.101 0.513*
SS 0.577 0.400.70 60.998.67 59.508.96 0.075 0.412*
AT 0.737 0.630.81 52.667.46 51.968.22 0.269 0.586*

SC, Social/Communication; UB, Unusual Behaviors; SR, Self-Regulation; PS, Peer Socialization; AS, Adult Socialization; SER, Social/Emotional Reciprocity; AL, Atypical Lan-
guage; ST, Stereotypy; BR, Behavioral Rigidity; SS, Sensory Sensitivity; AT, Attention; ICC, Intra-Class Correlation; T-score, Total Score. Data are represented by the mean and
standard deviation.
*
All r values are moderate correlations.

77% in the current study sample. The data indicated good dis-
criminant ability of the Chinese parent version of the ASRS.
4. Discussion
In this article, we assessed the validity and reliability of the
Chinese parent version of the ASRS (for children 618 years old).
All original items remained in the Chinese parent version of the
ASRS, and the scale factor structure remained the same regardless
of whether the general or clinical case sample were considered in
this study. Our ndings show that the Chinese parent version of
the ASRS has good validity and reliability, with the same items and
factor structure as the original ASRS.
As predicted from previous studies, the ASRS scale scores for
boys in the general sample were signicantly higher than those for
girls. Previous studies have indicated that boys and girls have
different proles of social and communication developmental
trajectories, particularly a higher rate of difculties in social and
communicational skills for boys (Leaper, 1994; Gagnon and Simon,
2011). Social communication dysfunction is one of the core
symptoms of ASDs. Epidemiological research also shows that the
prevalence of ASDs dramatically differs between males and fe-
males (the malefemale ratio is approximately 4:1) (Simonoff
et al., 2008; Kim et al., 2011; Mandy et al., 2012). One possible
explanation is the gender difference in neurodevelopment
(OConnor and Joffe, 2014). In this study, the mean subscale raw
scores and T-scores slightly differed among the 4 cities, which
were selected in regions that differ slightly in their cultural
background and level of economic development; it is likely that
these differences reect true variability in the population that was
appropriately reected in our representative sample. Interestingly,
we nd a contrary result that girls in the clinical sample have
signicantly higher SC and UB scores and T-scores than boys do. To
our knowledge, the prevalence of ASDs is higher in boys than in
girls, but the symptoms experienced by girls are more severe than
those experienced by boys (Bejerot and Eriksson, 2014).
The screening subscales demonstrated high internal reliability
coefcients. There were eight treatment subscales with Cronbachs
alphas ranging from 0.58 to 0.81. Most subscales had acceptable
internal consistency (alpha 40.60); alpha coefcients are inu-
enced by the average inter-item correlation in a composite form
and by the number of items pertaining to this composite value.
Lower values for internal consistency were obtained for subscales
that had relatively fewer items, whereas all scales with 10 or more
items had alpha coefcients above 0.80. The questionnaires
Cronbachs alpha value 40.8 is suitable for scientic research
(Connelly, 2011). Therefore, the results of our study demonstrate
that the Chinese parent version of the ASRS has good internal
consistency. The testretest reliability reects the stability of the
scale; as in previous studies, the testretest reliability assessment
shows that the Chinese parent version of the ASRS has good test
retest reliability and an acceptable (low) level of measurement
error. The English parent version of the ASRS also has good relia-
bility (Goldstein and Naglieri, 2009).
Of the several types of validity, we evaluate the construct va-
lidity, concurrent validity and discriminant validity of the Chinese
parent version of the ASRS. The results (KMO 40.9, Bartletts
test o0.01) demonstrated that the data are suitable for factor
analysis (Velicer et al., 2000). The results for construct validity
showed the tting indices (CFI, GFI, AGFI, and NNFI) based on CFA,
supporting the 3-factor structure proposed initially for the

Table 4
Concurrent validity of the Chinese parent version of the ASRS compared with the SRS. Pearsons correlations between the subscales of the Chinese ASRS and SRS (n 211).

ASRS Scales SRS

Social awareness Social cognition Social communication Social motivation Autistic mannerisms Total score

SC 0.467 0.553 0.596 0.511 0.261 0.581

UB 0.152 0.363 0.305 0.385 0.429 0.404
SR 0.518 0.347 0.505 0.355 0.421 0.519
T-score 0.556 0.619 0.694 0.609 0.521 0.732

SC, Social/Communication; UB, Unusual Behaviors; SR, Self-Regulation; T-score, Total Score.
260 H. Zhou et al. / Psychiatry Research 230 (2015) 255261

Table 5 the ASRS, which achieves a sensitivity of 94.7% and a specicity of

Discriminant validity of the Chinese parent version of the ASRS. 77% in distinguishing cases from non-cases in the study sample.
All the data indicated that the ASRS has excellent discriminant
Scales Community Clinical sample t Value Cohens d
sample validity and is an effective instrument for screening for ASD in a
(n 1625) (n 190) Chinese general sample.

T-score 54.63 7 6.92 69.177 6.38  29.00 2.23

ASRS scales SC 56.377 9.39 74.58 7 8.02  26.95 2.27
4.1. Limitations
UB 58.067 6.27 64.817 5.92  14.82 1.14
SR 47.147 8.29 59.647 7.28  20.91 1.72 To the best of our knowledge, this is the rst multi-site and
DSM-IV-TR scale 56.81 7 5.95 68.637 4.87  27.72 2.43 large-scale study using both general sample and clinic cases to
Treatment PS 52.02 7 8.38 73.26 7 5.63  35.82 3.78
validate the Chinese parent version of the ASRS by performing
scales AS 49.237 8.64 64.457 8.31  24.23 1.83
SER 55.277 8.74 validity and reliability analyses. Our results demonstrate that the
71.25 7 7.69  28.00 2.08 Chinese parent version of the ASRS is a useful and reliable national
AL 53.53 7 7.84 66.777 9.46  19.52 1.40 screening tool for autistic behavior. However, the limitation of this
ST 55.59 7 6.93 61.047 8.21  9.22 0.66
study is the representativeness of the samples; because our sam-
BR 57.32 7 6.94 60.767 8.07  5.94 0.43
SS 59.147 9.46 64.767 9.75  8.11 0.58 ple was obtained from four cities, these results may not be gen-
AT 49.367 8.41 61.577 7.95  20.91 1.54 eralized to the entire population in mainland China. Another
limitation is that the CFA results indicate a relatively good model
SC, Social/Communication; UB, Unusual Behaviors; SR, Self-Regulation; PS, Peer t. In general, tting indices 40.9 indicate fairly good construct
Socialization; AS, Adult Socialization; SER, Social/Emotional Reciprocity; AL, Aty-
pical Language; ST, Stereotypy; BR, Behavioral Rigidity; SS, Sensory Sensitivity; AT,
validity of a questionnaire (Beauducel and Rabe, 2009). In parti-
Attention; T-score, Total Score. Data are represented by the mean and standard cular, the ASRS is a newly developed assessment instrument. Be-
deviation. All P values are signicant at the 0.001 level. cause of the lack of studies conducting CFA on the ASRS in dif-
ferent countries, a comparison of the present results and previous
ndings cannot be made with respect to these issues. Therefore,
comprehensive factor analysis is necessary in further research to
reassess the scale items and structure based on the Chinese
culture.

5. Conclusion

In summary, we developed the Chinese parent version of the

ASRS for children aged 612 years. The psychometric properties of
this version are excellent, as shown by the high internal con-
sistency, good testretest reliability, and discriminant and con-
current validity. The Chinese parent version of the ASRS is there-
fore a reliable and valid instrument for national ASD screening in
the general population of children in China. Future studies should
investigate the validity and reliability of other forms of the ASRS
(25 years old).

Fig. 3. Receiver operating characteristics (ROC) for ASRS and SRS; ASRS, Autism
spectrum rating scale; SRS, Social Responsiveness Scale.
Conict of interest

instrument. The t indices indicate that the ASRS has relatively
good construct validity. Previous studies have also shown that the
cultural setting can affect performance on the scales (McCrae et al.,
1998). To test the concurrent validity, we use the SRS as the ex-
ternal criterion. The high correlation between the total scores
(r 0.732) of the two scales show the homogeneity of these
measurements. The fact that some subscales have low correlations
is expected because the factor structure differs between the two
instruments. Thus, the lowest correlation observed (0.152) is be-
tween 2 subscales that measure different constructs and that have
component items that are not comparable. It is necessary for the
screening tool to have good discriminant ability between a general
sample and clinical cases (Lucas et al., 1996). The comparison be-
tween the general sample and clinical case sample shows robust
mean differences in all scores; in particular, the effective size of
the three screening scales and T-scores was greater than 1, sup-
porting the discriminating ability of the Chinese parent version of
the ASRS. The excellent AUC estimation from the ROC analyses
indicates strong and equally high discriminant validity of the total
ASRS scores compared with the SRS. No gender difference was
found for the ASRS. Our data suggest an optimal cutoff of 60 for
The authors declare that they have no competing interests.
Contributions
Dr. Hao Zhou, who wrote the manuscript, is a Ph.D. student at
the Childrens Hospital of Fudan University. This study is part of
her dissertation work. Xiaoling Ge, Lili Zhang, Caihong Sun, and
Hongzhu Deng collected the data. Hao Zhou and Weili Yan com-
pleted the data analysis. Yimin Wang, Weili Yan, Eric Fombonne,
Yong-Hui Jiang and Yi Wang revised the manuscript. Lijie Wu,
Xiaobing Zou, Xuerong Luo, Kun Xia, Xiu Xu, Weili Yan, Eric
Fombonne, Yong-Hui Jiang, and Yi Wang conducted and designed
the study.
Acknowledgments
This study was supported by the National Health and Family
Planning Commission of the Peoples Republic of China (Grant
number: 201302002; ClinicalTrials.gov number NCT 02200679).
 H. Zhou et al. / Psychiatry Research 230 (2015) 255261
We would like to thank all of the parents who participated in this
project.
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