Child Sexual Behavior Inventory: A Dutch-speaking Normative Sample

Eric Schoentjes, Dirk Deboutte and William Friedrich

Pediatrics 1999;104;885-893
DOI: 10.1542/peds.104.4.885

This information is current as of March 22, 2007

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 Child Sexual Behavior Inventory: A Dutch-speaking Normative Sample

Eric Schoentjes, MD*; Dirk Deboutte, PhD‡; and William Friedrich, PhD§

ABSTRACT. Objectives. To describe normative sex- development, and an explosion of studies about sex-
ual behavior in Dutch-speaking children; to assess the ual abuse, only a few studies have concentrated on
frequencies of different types of sexual behaviors re- normal child sexual development and experience.2
ported in children by their parents; to analyze the rela- Until recently, knowledge about sexual development
tion of these sexual behaviors to demographic, personal, and behavior of children, mostly based on adult
familial, and general behavioral variables; and to com-
pare the Dutch-speaking sample with American samples.
recollection of sexual feeling or activities during
Method. Nine hundred seventeen children (2–12 childhood years, was often anecdotal or derived
years of age), screened to exclude sexual abuse, were from small or biased samples. Remarkably scarce
rated by their caregiver via parent report consisting of the information based on large-scale surveys or observa-
translated Dutch version of the Child Sexual Behavior tions exists with regard to child sexual development.
Inventory, the Child Behavior Checklist, a life event In the past decade however, the results of a few
checklist, and a questionnaire assessing family nudity large-scale surveys on this subject have been pub-
and parental attitudes regarding sexuality. lished.3–5 A promising instrument used in some of
Results. Frequencies of a wide variety of sexual be- these surveys is the Child Sexual Behavior Inventory
haviors for 2- to 5-, 6- to 9-, and 10- to 12-year-old children
are presented. Sexual behavior was found to be related to
(CSBI).3,4 This parental report measure consists of
the child’s age, maternal education, family nudity, and ;40 questions on sexual behavior and interest. It has
parental attitudes toward sexuality. The positive relation been well-validated in two large-scale surveys of 2-
to general behavioral problems was confirmed. Findings to 12-year-old children.3,4 Since its first publication in
were primarily similar to previously published American Pediatrics in 1991, this method has been increasingly
studies. used in different studies to measure and describe
Conclusion. Our study confirms that sexual behavior sexual behaviors for different categories of children.
in children is varied and related to developmental, per- Its use has also been recommended by different au-
sonal, and familial factors. The relative frequency of the thors for the assessment of sexually-abused chil-
wide variety of sexual behaviors in a Dutch-speaking 6 –10
dren.
normative sample is comparable to American samples.
Pediatrics 1999;104:885– 893; sexual behavior, children, Large-scale studies including direct observation of
family sexuality, Child Sexual Behavior Inventory. children’s sexual behavior, or questioning of the chil-
dren about their sexuality, have not yet been per-
formed to this date. Cultural attitudes and values
ABBREVIATIONS. CSBI, Child Sexual Behavior Inventory; CBCL, about sexuality, and in particular childhood sexual-
Child Behavior Checklist.
ity, certainly hamper this kind of research. However,
retrospective self-report studies, specifically adult

W
ith the ever-increasing focus on the sexual recollections about sexual feelings or activities as a
abuse of children, pediatricians are often child, have been used to document sexual behavior
confronted with questions from parents or in children as normal.
other caregivers about the normality of a child’s sex- Despite controversies about the reliance on paren-
ual behavior or interest in sexual matters. As Finkel- tal (or other caregivers) observations and reports on
hor1 wrote: “We know more about sexual deviance the behavior of their children, they are widely used
than we do about sexual normality. . . (We have) a in clinical and developmental research. Several rea-
vast ignorance of the forces governing the develop- sons support the use of parental report in research
ment and experience of sexual behavior in general.” about children’s development. First, is the expertise
Although in the last 3 or 4 decades there has been a of the parent, who typically is recognized as the most
significant increase in studies of infant and child knowledgeable about their young child’s life. Sec-
ondly, the questionnaire method allows more chil-
dren to be studied than the use of more intrusive
From the *Fund for Scientific Research, Flanders, Belgium; the ‡University methods like observation. Thirdly, the use of paren-
of Antwerp and Antwerp University Center for Child and Adolescent 11
tal questionnaires is relatively economical.
Psychiatry, Antwerp, Belgium; and the §Department of Psychiatry and
Psychology, Mayo Clinic and the Mayo Medical School, Rochester, Minne- Similar to other areas of child development, sexual
sota. behavior is influenced by environmental factors.
Received for publication Oct 13, 1998; accepted Mar 3, 1999. These factors are at the level of the society, and at the
Reprint requests to (E.S.) Antwerp University Center for Child and Ado- level of the family in which the child grows up.
lescent Psychiatry, Lindendreef 1, 2020 Antwerpen, Belgium. E-mail:
[email protected]
Friedrich et al3,4 demonstrated that sexual behavior
PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Acad- in children is related to the child’s family context,
emy of Pediatrics. most specifically, sexual behavior in the family and

PEDIATRICS Vol. 104 No. 4 October 1999 885

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the level of education of the mother. However, he questionnaires). This resulted in a total of 917 children, or 70.8% of
could not confirm the influence of ethnicity on the the returned questionnaires. This group of 917 children 2 to 12
years old, of Belgian or Dutch origin, and not suspected of having
sexual behavior in his normative sample. been sexually abused, constituted the normative sample used in
A modified version of the CSBI has been used all further analyses. Demographic data of our normative sample
previously to examine the sexual behavior and are presented in Table 1.
knowledge of two Dutch samples of 0- to 11-year-old
children.12,13 The results of these surveys confirmed Questionnaire
the influence of familial factors on the sexual behav- The 7-page questionnaire consisted of four sections: a demo-
graphic data sheet, a section consisting of questions about family
iors but found higher frequencies for a wide variety nudity and parental attitudes concerning sexuality, the CSBI, and
of sexual behaviors in comparison to the American the “problem behavior” portion of the Child Behavior Checklist
samples. Unfortunately these results can not be ex- (CBCL).
trapolated to the Dutch population because of an The first section of the questionnaire consisted of questions
concerning demographic and familial variables. This portion ob-
important recruitment bias in both studies, which tained information on the identity of the respondent in relation to
resulted in overrepresentation of higher social the child; the age and sex of the respondent and the child; the total
classes. number of children, separately for girls and boys in the family; the
For professionals to speak with authority about the rank-order of the child; the occupational and educational status of
normality or abnormality of the sexual behavior in the parents; the nationality and ethnic origin of the child; and a life
events checklist. The life event items obtained information on
children, it is useful for pediatricians to refer to a whether the child had ever experienced parental divorce or sep-
culturally relevant normative sample. The aim of the aration, physical abuse, parental death, parental illness requiring
present study was to adapt the CSBI for the Dutch hospitalization, and child illness requiring hospitalization. One
language and to use it in a large-scale community- item also screened for negative sexual experiences to identify
possible sexually-abused children.
based survey to describe the normative sexual be- The second section consisted of 4 questions related to family
havior of 2- to 12- year-old children in an urban area nudity (eg, “Your child can watch when you’re naked,” “Your
in Flanders, the Dutch-speaking part of Belgium. The child accompanies you in bath or shower”); 5 questions concern-
study also explored the relationship of socioeco- ing parental reactions to the sexual curiosity of the child (eg,
nomic and family variables to sexual behavior. To “How would you react if your child asked to look at your geni-
tals?,” “How would you react if your child watched adult movies
examine possible cultural influences on the sexual on television?”); and 4 questions concerning parental attitudes
behavior of children, the frequencies of a wide vari- toward sexuality (self-rating of permissiveness for masturbation,
ety of sexual behaviors were also compared with the homosexuality, and extramarital sex). In this second section the
frequencies in previously published American sam- respondent was requested to mention if he had ever experienced
“adverse sexual experiences during childhood that still hamper
ples. him as an adult”.
The third section consisted of the Dutch translation of the CSBI.
METHODS The adapted CSBI version used in this study consisted primarily
Sample of the 44 questions of the CSBI reported by Friedrich et al3 in his
publication Normative Sexual Behavior in Children. These questions
Study participants were derived from 14 schools in the urban were translated into Dutch by the first author and tested for
area of Antwerp (population: 462 880 inhabitants). These schools readability and comprehension by five parents. The questionnaire
were located in the inner city as well as in the suburbs of town. was then independently translated back to English by a blind
Private as well as state-owned public schools were included. All translator to check possible distortion of meaning as a result of the
the children in the participating schools were given a sealed translation process. To these 44 questions, 3 were added from the
envelope containing a questionnaire and an accompanying letter questionnaire used by Cohen-Kettenis and Sandfort13 in their sur-
that explained the aim of the study, presented the investigators, vey: “asks questions concerning sexuality,” “draws sex parts in
and gave guidelines concerning the completion of the question- pictures,” and “plays doctor” (a common Dutch expression for
naire. Depending on the age of the child, the envelope was either
given to the parents by the teachers or to the children, with
instructions to hand it over to their parents. It was assumed that TABLE 1. Demographic Data
parents of children from Belgian or Dutch nationality had suffi-
% Female 54.6
cient competence in Dutch to complete the questionnaire.
Child’s age, mean y, (SD) 6.02 (2.64)
In the accompanying letter the aim of the study was explained.
Maternal education, mean y, (SD) 19.13 (1.93)
Participation in this survey was nonobligatory and the parents
Paternal education, mean y, (SD) 19.17 (2.29)
were guaranteed anonymity. The letter stressed the preference for
Maternal professional activity (percentage)
the female caregiver of the child to complete the questionnaires.
Unemployed/housewife 13.1
The parents were instructed to return the completed (or uncom-
Unskilled worker 3.3
pleted) questionnaires in a closed envelope that accompanied the
Skilled worker/lower employee 9.2
questionnaire. This envelope was collected by the teacher of their
Employee 39.9
child. After 3 weeks the investigators collected the questionnaires
Self-employed person 9.4
in the schools.
Public servant/teacher/higher employee 18.3
The recruitment occurred in two phases. During the first phase,
Executive/independent profession 6.8
from January 1997 to February 1997, 1318 questionnaires were
Paternal professional activity (percentage)
distributed in elementary schools; ie, children ages 6 through 12
Unemployed 6.1
years. In the second phase, from November 1997 until January
Unskilled worker 0.6
1998, 1248 questionnaires were distributed in nursery schools; ie,
Skilled worker/lower employee 21.2
children ages 2 through 6 years.
Employee 25.8
A total of 2566 questionnaires were distributed and 1294 were
Self-employed person 13.6
returned to the investigators (50.4%). From this total, 377 were
Public servant/teacher/higher employee 17.3
excluded for various reasons (192 were blank; 84 had been incom-
Executive/independent profession 15.4
pletely or incorrectly answered; 71 questionnaires were excluded
% White 100
because the children were not of Belgian or Dutch nationality; 7
% Divorced or separated 17.1
questionnaires because the children fell outside the age limits, ie,
% Female respondents 92.2
.12 years old). Questionnaires for children whose parents re-
Total n 5 917
ported their having been sexually abused were also excluded (23

886 CHILD SEXUAL BEHAVIOR INVENTORY

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mutual physical-genital explorative activity in children). Question Age Effect
44 of the CSBI-1 (“other sexual behavior [please describe]”) was
recorded but was not used for further analysis because of the We examined the age effect on the CSBI item mean
heterogeneity of the responses. Like the original CSBI, the Dutch score. Similar to the analysis used in Friedrich et al,3
translation asks the respondent to score the listed sexual behaviors the item mean score of the first 35 items of the CSBI
according to their frequency in the past 6 months. One can choose was graphically plotted against the age (Fig 1). Item
between 4 levels of frequency; ie, 0, never; 1, less than once a mean score was calculated by dividing the total score
month; 2, 1 to 3 times a month; and 3, at least once a week.
Similar to the first large-scale survey accomplished by Friedrich by the number of items (total score up to 105 [35 3 3]
et al,3 the last section consisted of the “problem behavior” portion 4 35). The plotted scores show a decline with in-
of the CBCL. This widely-used and well-validated instrument, creasing age. Our results confirmed that the 2- to
measures a wide range of behavioral problems. To encompass the 5-year-old children are relatively sexual compared
age distribution of our population, two versions were used, the
99-item 2- to 3-year-old version and the 113-item 4- to 18-year-old with the 10- to 12-year-old children and this is true
version. Total, internalizing, and externalizing T scores were for both genders. The steepest drop in item mean
scored for each child. score for both genders occurs at 5 years of age. An-
other drop occurs at 8 years of age for boys and 9
RESULTS years of age for girls. These findings are comparable
Type of Reporter to those of the American sample described by
Mothers comprised the majority of responders Friedrich et al4 in 1998. On the other hand, only the
(92.2%), but rather than discarding fathers automat- boys scored an increase in item mean score at the age
ically, the differences between fathers and mothers of 12 in our sample. This increase was described by
were first calculated. The relation of the gender of the Friedrich et al4 but for both genders, and is probably
responder to the CSBI mean total score was exam- attributable to the increased interest in sexual mat-
ined with multiple regression analysis. Four demo- ters (as reflected for example in the items: “is very
graphic variables were entered first as a block; ie, age interested in opposite sex” or “tries to view pictures
and gender of the child, maternal education, and of nude or partially dressed people”). The correlation
parental professional activity. Parental professional of age and the item mean score was significant (r 5
activity was used as an alternative parameter for 2.34, P , .0001).
family income because questions about family in-
come are not well-accepted in Belgium. A score was Endorsement Frequencies of the Items
attributed to each professional category (from 1 for The proportion of children endorsing each item
“unemployed/housewife” to 7 for “executive/inde- was calculated for the entire normative sample. En-
pendent profession”). An average score was calcu- dorsement was defined as a score of either 1, 2, or 3,
lated when both parents were working outside meaning the child had exhibited that behavior at
home, with parental professional activity reflecting least once in the past 6 months. The endorsement
this composite. frequencies are listed in Table 2. Although some
The gender of the respondent was added in the sexual behaviors are extremely uncommon (eg, “puts
next step of the regression analysis. This step only mouth on another child/adult sex parts,” “ask others
marginally increased the explained variance as re- to do sex acts,” or “puts object in vagina/rectum”),
flected in an R2 5 .001, and the gender of the respon- every item was endorsed at least by a few parents in
dent was not significantly related to the CSBI total this sample.
mean score after the variance contributed by the four At the other extreme, 24 out of 43 items were
demographic variables was considered (P 5 .410). endorsed by .10% and 4 out of 43 by .50%. In the
This finding supported our decision to include the second and third columns of Table 2 the relative
questionnaires completed by a male caregiver in our endorsement frequencies of identical and similar
normative sample. items of two other published CSBI-samples are listed

Fig 1. Normative sample: Child Sexual Behavior

Inventory item mean score for boys and girls
across age groups.

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TABLE 2. Rank Order of Endorsement Frequencies for Shared Items of the CSBI-Versions
No. Item (Abbreviated) CSBI-Antwerp CSBI-13 CSBI-34
(n 5 917) (n 5 880) (n 5 1114)
10 Puts mouth on another child’s/adult’s sex parts 0.2 0.1 0.2
29 Wants to watch TV nudity 0.7 2.7 7.7
15 Ask others to engage in sex acts 1.0 0.4 0.3
17 Puts objects in vagina/rectum 1.6 0.9 0.8
42 Touches animals’ sex parts 1.6 1.3 1.5
7 Masturbates with object 2.0 0.8 3.9
19 Imitates sexual behavior with dolls/stuffed animal 2.9 3.2 1.6
28 Undresses other children 3.1 2.6 1.2
16 Rubs body against people or furniture 4.4 6.7 4.3
14 Makes sexual sounds 4.6 1.4 1.4
9 Imitates the act of sexual intercourse 5.0 1.1 –
40 Overly friendly with men 5.2 7.1 2.8
2 Wants to be opposite sex 5.7 4.9 5.4
30 Puts tongue in mouth when kissing 5.9 2.5 2.3
37 Puts mouth on breast 7.1 2.6 3.0
36 Stands too close 7.2 11.6 21.3
4 Masturbates with hands 7.5 15.3 12.4
33 If girl, overly aggressive, if boy, overly passive 7.9 10.4 –
45 Draws sex parts 7.9 – 2.3
13 Pretends to be opposite sex when playing 8.3 13.0 –
31 Hugs adults not well-known 8.4 7.3 9.5
32 Shows sex parts to children 9.5 8.1 5.3
1 Dresses like opposite sex 11.8 5.8 9.3
20 Shows sex parts to adults 12.9 16.0 9.8
22 Talks about sex acts 12.9 4.7 5.3
27 Talks flirtatiously 13.1 10.6 4.9
8 Touches other people’s sex parts 14.1 6.0 –
12 Uses words that describe sex acts 14.3 8.8 –
21 Tries to look at pictures of nude people 16.3 15.5 6.7
3 Touches sex parts in public 22.1 19.7 14.4
41 Shy about undressing 22.9 38.7 –
34 Very interested in opposite sex 24.3 23.0 17.1
18 Tries to look at people when they are nude 31.7 28.5 21.4
25 Sits with crotch or underwear exposed 40.0 36.4 –
5 Scratches anal and/or crotch area 42.6 52.2 –
46 Plays doctor 42.8 – –
43 Walks around house without clothes 44.5 41.9 –
6 Touches breast 45.9 30.7 27.3
23 Kisses adults not in the family 46.5 36.2 –
35 If boy, plays girl’s toys, if girl, plays boy’s toys 46.5 53.9 –
44 Ask questions about sexuality 48.9 – –
26 Kisses other children not in the family 49.1 33.9 –
24 Undresses self in front of others 52.6 41.2 –
38 Likes to walk in underclothes 54.0 52.9 –
39 Shy with strange men 62.5 64.5 –
11 Touches sex parts at home 63.8 45.8 –

to enable comparison with the present sample. The quencies for the different items. Similar to the anal-
age and sex distributions of these samples differ only ysis of Friedrich et al,4 the children were grouped
slightly (the age and sex distribution of the sample into three age clusters. The rationale for this catego-
can be found in Table 3.). A large majority of items rization can be found in the developmental trend of
have similar endorsement frequencies across the the item mean score as reflected in Fig 1 and as
three samples. This can be illustrated by the fact that discussed above. The groups are: 2- to 5-year-olds, 6-
only 21 out of 70 possible two-group comparisons to 9-year-olds, and 10- to 12-year-olds. The frequen-
differ by .5% and only 6 differ by .10%. cies of sexual behavior in these three age groups are
presented in Table 4. An examination of Table 4
Developmental Course suggests that three categories of sexual behavior can
As suggested by the age effect on the CSBI total be observed when one takes the age of the child into
score, age was considered in the calculation of fre- account. The vast majority of the sexual behaviors as

TABLE 3. Age and Sex Distribution of the Normative Sample

Age (Year) Total
2 3 4 5 6 7 8 9 10 11 12
Male 15 72 65 79 44 37 32 25 24 18 5 416
Female 23 74 66 76 56 40 42 35 52 26 11 501
Total 38 146 131 155 100 77 74 60 76 44 16 917

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TABLE 4. Simple Endorsement Frequencies of Sexual Behaviors for the Three Age Groups
No. Item (Abbreviated) 2–5 Years 6–9 Years 10–12 Years x2 Cochran’s
(n 5 470) (n 5 311) (n 5 136) P P
1. Dresses like opposite sex 16.2 9.0 2.9 ,.0001 ,.00001
2. Wants to be opposite sex 9.8 1.0 2.2 ,.00001 ,.00001
3. Touches sex parts in public 30.0 16.1 8.8 ,.00001 ,.00001
4. Masturbates with hands 9.2 6.1 5.2 NS –
5. Scratches anal and/or crotch area 53.4 36.0 20.6 ,.00001 ,.00001
6. Touches breast 63.0 35.7 10.3 ,.00001 ,.00001
7. Masturbates with object 3.2 0.3 1.5 ,.02 ,.05
8. Touches other people’s sex parts 21.9 7.7 1.5 ,.00001 ,.00001
9. Imitates the act of sexual intercourse 2.3 8.7 5.9 ,.001 ,.005
10. Puts mouth on another child’s/adult’s sex parts 0.2 0.3 0.0 NS –
11. Touches sex parts at home 78.3 56.0 31.6 ,.00001 ,.00001
12. Uses words that describe sex acts 3.6 24.4 27.9 ,.00001 ,.00001
13. Pretends to be opposite sex when playing 13.8 2.9 1.5 ,.00001 ,.00001
14. Makes sexual sounds 2.3 6.8 7.4 ,.005 ,.005
15. Ask others to do sex acts 0.9 1.6 0.0 NS –
16. Rubs body against people or furniture 5.3 3.5 2.9 NS –
17. Puts objects in vagina/rectum 3.0 0.3 0.0 ,.005 ,.005
18. Tries to look at people when they are nude 37.2 28.9 19.1 ,.001 ,.0005
19. Imitates sexual behavior with dolls/stuffed animal 2.6 3.5 2.9 NS –
20. Shows sex parts to adults 20.9 4.5 4.4 ,.00001 ,.00001
21. Tries to look at pictures of nude people 9.8 21.5 26.5 ,.00001 ,.00001
22. Talks about sex acts 4.5 18.0 30.2 ,.00001 ,.00001
23. Kisses adults not in the family 57.0 37.6 30.2 ,.00001 ,.00001
24. Undresses self in front of others 62.6 48.6 27.2 ,.00001 ,.00001
25. Sits with crotch or underwear exposed 50.4 34.7 16.2 ,.00001 ,.00001
26. Kisses other children not in the family 63.4 38.6 23.5 ,.00001 ,.00001
27. Talks flirtatiously 16.0 12.9 3.7 ,.001 ,.001
28. Undresses other children 4.9 1.3 0.7 ,.005 ,.005
29. Wants to watch TV nudity 0.4 1.0 0.7 NS –
30. Puts tongue in mouth when kissing 0.8 4.5 1.5 ,.01 ,.01
31. Hugs adults not well-known 11.9 5.2 3.7 ,.0005 ,.0005
32. Shows sex parts to children 13.2 7.1 2.2 ,.001 ,.0001
33. If girl overly aggressive, if boy overly passive 10.0 6.4 3.7 ,.05 ,.01
34. Very interested in opposite sex 23.4 24.4 27.2 NS –
35. If boy, plays girl’s toys, if girl, plays boy’s toys 59.4 38.3 20.6 ,.00001 ,.00001
36. Stands too close 8.9 5.8 4.4 NS –
37. Puts mouth on breast 8.7 7.7 0.0 ,.01 ,.005
38. Likes to walk in underclothes 63.4 51.5 27.2 ,.00001 ,.00001
39. Shy with men they don’t know 71.5 58.2 41.2 ,.00001 ,.00001
40. Overly friendly with men 6.6 3.9 3.7 NS –
41. Shy about undressing 15.3 30.2 32.4 ,.00001 ,.00001
42. Touches animals’ sex parts 2.6 1.0 0.0 NS –
43. Walks around house without clothes 57.5 38.6 13.2 ,.00001 ,.00001
44. Ask questions about sexuality 33.6 64.6 65.4 ,.00001 ,.00001
45. Draws sex parts 4.9 12.2 8.1 ,.001 ,.05
46. Plays doctor 53.0 39.2 15.4 ,.00001 ,.00001

described by the items tend to decrease in endorse- were too low, age categories were grouped. To eval-
ment frequency at increasing age (eg, “touches sex uate the age effect on the individual endorsement
parts in public,” “touches breasts,” “shows sex parts frequencies of the items, Cochran’s test of linear
to adult,” “tries to look at people when nude,” trend was computed (see Table 4).
“dresses like opposite sex”). Some seem to be more In summary, the vast majority of the items (34 of
frequent in the older-age categories (eg, “talks about 46) reflected a significant age trend (previous prob-
sex acts,” “shy about undressing,” “tries to look at ability established at .01 because of the number of
pictures of nude people”), where others do not seem calculations). Twenty-six of the behaviors were more
to vary between the different age-categories (eg, “im- common in the younger age group and 8 were more
itates sexual behavior with dolls,” “very interested in common in one of both of the older groups.
opposite sex,” “puts mouth on another child/adult
sex parts”). Internal Reliability of the Dutch Translation of the
A x2 analysis was performed to investigate these CSBI
impressions in a more formal manner. Frequency Cronbach’s a coefficient was computed and factor
tables for each item were constructed by putting the analysis was performed to assess the interrelation-
three age-categories in columns and the presence or ship among the 46 items of the Dutch translation of
absence of that behavior in rows (an item score the CSBI. All items were positively correlated with
equalling 0 meant that particular behavior was not the total CSBI score and the Cronbach’s a coefficient
observed by the parents, item scores of 1, 2, or 3 for the 46 items was 0.86. This high a coefficient is an
meant that the behavior had been observed at least argument in favor of the items being added to cal-
once in the past 6 months). When table frequencies culate a total score for the CSBI. Nevertheless, a

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principal component analysis with varimax rotation However the interrelationships among the constitu-
revealed the presence of 7 stable factors. Loading of ent items in these seven domains, as reflected in their
,0.3 on one factor, and a difference of ,0.1 between individual Cronbach’s a coefficient (Table 5), is rel-
the loading of a single item on 2 different factors, atively modest. Future research is needed to further
were used as exclusionary criteria. This resulted in explore these underlying dimensions with a more
the exclusion of 7 out of 46 items. According to their heterogeneous sample to better define the factors
constituent items the 7 factors, computed by princi- through deleting or rephrasing a number of existing
pal component analysis, could be labeled as: “shame- items or by introducing new ones.
lessness,” “sexual interest,” “boundary problems,”
“gender identity problems,” “sexualized play,” “sex- Relationship of Sexual Behavior to Demographic and
ual intrusiveness,” and “genital manipulation” (see Family Variables
Table 5). Multiple regression analysis was used to examine
The presence of underlying dimensions of behav- the relation of demographic and family variables
ior in the CSBI could not be determined in the first with the CSBI mean total score. The dependent vari-
large-scale sample published by Friedrich et al14in able was defined as the mean total score on the 46
1991. However in a recent publication he suggested items of the translated CSBI. Four demographic vari-
that sexual behavior was not an unidimensional phe- ables were entered as a block; ie, age and gender of
nomenon, and in his most recent sample, six to eight the child, maternal education, and parental profes-
factors could be identified. sional activity.
The factor analysis computed on the Dutch-speak- Only two variables were significantly related to
ing sample seems to support these suggestions. the CSBI mean total score; ie, age (F 5 99.9, R2 5

TABLE 5. Factor Loadings of the CSBI-items in a Seven-factor Model

No.* Item (Abbreviated) Loadings
1 2 3 4 5 6 7
25 Sits with crotch or underwear exposed 0.733 20.014 20.003 0.092 0.054 0.150 0.12
24 Undresses self in front of others 0.728 0.018 0.122 0.011 20.075 0.058 0.01
43 Walks around house without clothes 0.674 20.019 20.013 0.115 0.014 0.139 0.21
26 Kisses other children not in the family 0.648 0.071 0.354 0.051 20.110 0.047 0.02
38 Likes to walk in underclothes 0.637 0.060 0.015 0.128 0.090 0.117 0.18
23 Kisses adults not in the family 0.616 0.068 0.317 0.006 20.087 20.069 20.01
22 Talks about sex acts 0.049 0.697 0.042 20.086 0.254 20.111 20.08
21 Tries to look at pictures of nude people 20.059 0.684 0.052 0.086 0.019 0.013 0.16
44 Ask questions about sexuality 0.091 0.648 0.040 20.039 0.042 0.031 0.10
12 Uses words that describe sex acts 0.016 0.597 0.061 20.114 0.305 20.070 20.06
34 Very interested in opposite sex 0.107 0.485 0.204 0.128 20.043 0.200 0.19
41 Shy about undressing 20.109 0.413 20.113 0.075 20.084 0.051 0.00
18 Tries to look at people when they are nude 0.264 0.386 0.103 0.193 0.039 0.116 0.22
45 Draws sex parts 0.111 0.326 0.036 20.048 0.187 0.197 20.09
29 Wants to watch TV nudity 0.025 0.316 20.105 0.230 20.197 20.159 0.26
36 Stands to close 0.065 20.007 0.704 0.020 0.014 0.009 0.08
40 Overly friendly with men 20.015 20.030 0.696 0.169 0.060 0.047 0.02
31 Hugs adults not well-known 0.094 20.017 0.641 20.041 0.012 0.112 0.05
33 If girl overly aggressive, if boy overly 0.173 0.100 0.420 0.038 0.051 20.040 0.05
passive
27 Talks flirtatiously 0.166 0.164 0.410 0.096 20.042 0.053 0.26
13 Pretends to be opposite sex when playing 0.124 0.057 0.103 0.814 0.047 0.046 0.06
2 Wants to be opposite sex 0.041 20.036 0.069 0.780 0.004 0.101 0.16
1 Dresses like opposite sex 0.156 0.060 0.064 0.633 20.025 20.038 0.01
9 Imitates the act of sexual intercourse 20.038 0.143 0.021 20.084 0.689 0.048 0.00
19 Imitates sexual behavior dolls/stuffed animal 20.012 0.121 0.029 0.058 0.668 0.029 20.03
7 Masturbates with object 0.055 20.193 20.081 0.017 0.544 20.011 0.20
14 Makes sexual sounds 20.039 0.270 0.104 0.040 0.539 20.064 0.05
42 Touches animals’ sex parts 0.089 0.044 0.018 0.240 0.179 0.632 20.09
37 Puts mouth on breast 0.064 0.125 0.148 20.103 20.033 0.569 0.24
17 Puts objects in vagina/rectum 0.069 20.082 20.042 0.114 0.013 0.565 0.05
30 Puts tongue in mouth when kissing 0.132 0.087 0.285 20.053 20.022 0.533 0.10
10 Puts mouth on another child’s/adult’s sex 0.038 0.012 20.061 20.061 20.046 0.390 20.04
parts
4 Masturbates with hands 0.068 0.078 0.055 0.057 20.038 20.150 0.62
11 Touches sex parts at home 0.434 0.033 20.031 0.064 0.127 0.073 0.54
3 Touches sex parts in public 0.321 20.071 0.020 0.109 0.171 0.010 0.52
32 Shows sex parts to children 0.050 0.096 0.126 0.126 20.012 0.372 0.46
15 Ask others to do sex acts 20.129 0.151 0.149 20.161 0.030 0.033 0.46
20 Shows sex parts to adults 0.237 0.031 0.198 0.157 20.062 0.191 0.45
5 Scratches anal and/or crotch area 0.303 0.004 0.088 0.129 0.220 0.142 0.44

Percent of total variance explained 8.88% 7.11% 5.90% 5.39% 4.97% 4.99% 6.03%
Cronbach’s a 0.81 0.67 0.57 0.70 0.56 0.49 0.66
* Items numbers 6, 8, 16, 28, 35, 39, and 46 left out.

890 CHILD SEXUAL BEHAVIOR INVENTORY

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.108, P , .000001) and maternal education (F 5 11.9, nalizing T score reflects the degree of problems re-
R2 5 .016, P , .00001). Together they accounted for lated to depression, anxiety, somatic concerns, and
12.4% of the explained variance. Gender and paren- withdrawn behavior, whereas the externalizing T
tal professional activity were not significantly related score reflects delinquent and aggressive behavior.15
to the CSBI mean total score after the variance con- The normality of our sample regarding behavioral
tributed by age and maternal education was consid- problems was first examined. The CBCL internaliz-
ered. These findings confirm the age effect on the ing and externalizing T scores are constructed so that
CSBI total mean score, ie, younger children have they have a mean score of 50 and a standard devia-
significantly higher scores than older children. Ma- tion of 10. For the 2- and 3-year-old children (scored
ternal education is also related to the CSBI score, in by the 99 item 2- to 3-year-old version) the mean and
that mothers with higher levels of education report standard deviation in our sample were, respectively,
more sexual behavior than less educated mothers. 47.4 and 9.5 for the internalizing score and 46.8 and
The relation of a number of child and family vari- 9.7 for the externalizing score. Thus the 2- and
ables to the CSBI total mean score were then exam- 3-year-old children in our sample tend to have
ined in the normative sample of 917 children. To slightly lower externalizing and internalizing T
determine the unique variance accounted by a cer- scores than those in the normative sample used for
tain child or family variable, the four demographic computer scoring. The 4- to 12-year-old children in
variables (age and gender of the child, maternal ed- our sample (scored by the 113 item 4- to 16-year-old
ucation, and parental professional activity) were first version) did not differ from the normative sample
entered as a block, and at the next step, one of these used for computer scoring (mean score and standard
child or family variables was added. The following deviation for internalizing and externalizing T score,
child and family variables were examined: whether respectively, 50.5, 10.3 and 50.0, 10.5).
the child had been victim of physical abuse, the To examine the relation of CBCL internalizing and
marital status of the parents, the total number of externalizing T score with the CSBI mean total score,
children in the family, and whether the respondent multiple regression analysis was used. The depen-
had had adverse sexual experiences during child- dent variable was defined as the mean total score on
hood. Of the four variables examined, three were the 46 items of the translated CSBI, and the four
significantly related to the CSBI total mean score, demographic variables (age and gender of the child,
namely physical abuse of the child (F 5 9.5, R2 5 .01, maternal education, and parental professional activ-
P , .003), marital status (F 5 8.1, R2 5 .008, P , .005), ity) were first entered as a block.
and total number of children (F 5 6.1, R2 5 .006, P , In a next step the relations of the CBCL internal-
.02). These three variables, although significantly re- izing and externalizing T score to the CSBI total
lated to the CSBI mean total score, typically account mean score were separately examined. Both internal-
for ,1% of the explained variance. izing and externalizing T scores from the CBCL were
An analogous strategy was used to examine the significantly related to the CSBI total mean score,
relation of CSBI total mean score to family nudity, even after removing the contribution of the four
parental attitudes toward sexuality, and parental re- demographic variables (F 5 85.4, R2 5 .096, P ,
sponse to the sexual curiosity of their child. The four .00001, and F 5 124, R2 5 .133, P , .00001, respec-
demographic variables were first entered as a block. tively). It seems that parents who report more behav-
In three consecutive steps the mean scores for the ioral problems in their child, also report higher levels
questions concerning familial nudity, parental atti- of sexual behavior. This finding is similar to obser-
tude toward sexuality, and parental response to the vations in the previous studies that examined this
sexual curiosity of their child were added to the relationship.
multiple regression analysis. All three of these con-
secutively added variables were significantly related DISCUSSION
to the CSBI total mean score (respectively, P , Our study examined the frequencies of a wide
.00005, P , .001, and P , .03) and together accounted variety of sexual behaviors in a normative sample of
for 11.4% of the explained variance (respectively, 917 2- to 12-year-old Dutch-speaking children. A par-
R2 5 .059, R2 5 .044, R2 5 .011). This confirms the ent report measure, the CSBI, was used in this study.
findings of previous studies that parents who report The strategy used to collect a representative sample
a more permissive approach to familial nudity, co- was different from that used in two previous large-
bathing, sexual curiosity of their child, homosexual- scale surveys performed by Friedrich et al.3,4 Instead
ity, or masturbation, also report higher levels of sex- of recruiting the population in pediatric clinics, fam-
ual behavior, even after controlling the effects of age ily medicine clinics, or day-care centers, the ques-
and gender of the child, maternal education, and tionnaires were distributed in a large number of
parental professional activity.3,4 schools, selected to evenly cover the urban area of a
large Belgian city. Care was taken to include private
schools as well as public schools to avoid bias based
Relationship of Sexual Behavior to General Behavior on religious beliefs, because in Belgium the vast ma-
Problems jority of private schools are Roman Catholic, whereas
The relationship of sexual behavior to general be- the state secular schools are pluralistic. The high
havioral problems was examined by using the inter- educational status of our sample is attributable to the
nalizing and externalizing T scores from the CBCL, fact that in Belgium the school attendance is compul-
which are widely used summary scores. The inter- sory until the age of 18 years. Most of our parents

ARTICLES 891
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(mean age of the reporting parents, 34.8 years) thus ual behavior (eg, “puts mouth on other child/adult
have a minimum educational status of 18 years. In sex parts,” “puts tongue in mouth when kissing,”
addition, both maternal and paternal reports were “touches animal sex parts,” “puts objects in vagina or
used, because we found that the gender of the re- rectum”).
porter added very little to the variance of the total The findings concerning the developmental trends
score. in the occurrence of different sexual behavior are
The screening question for sexually-abused chil- very similar to those reported by Friedrich et al3,4 in
dren detected 23 children or ;2.5% of the sample. the American normative samples. The individual en-
This proportion is smaller than that found by dorsement frequencies of the different items in the
Friedrich et al4 in his normative samples (;3.5%) and Dutch normative population as a whole, are also in
much smaller than the proportion that could be ex- the same order of magnitude as those found in the
pected based on the epidemiologic data concerning two other large-scale American samples. These find-
the presence of sexually-abused children in the gen- ings seem to suggest that there are no important
eral population. This important discrepancy could differences in the development and characteristics of
partially be explained by the fact that parents of sexual behavior in 2- to 12-year-old Belgian and
sexually-abused children most probably decided not American children.
to participate in the survey and did not return their This relative absence of differences is in marked
questionnaire. Another possible explanation is that contrast to two Dutch studies that used a portion of
whether a child ,12 years of age is sexually abused, the CSBI. Possible explanations for the differences
may be overlooked by caregivers, attributable to the are several. The first is that a very biased sample (1%
fact that a large portion of the disclosures of sexual of the total possible) was used in one study.13 The
abuse take place in preadolescent or adolescent second is that a pediatrician well-known to the par-
years. Epidemiologic data from the Flanders Child ents collected the data in the other.12
Welfare Department report a percentage of 43% of The relationship of sexual behavior and a number
disclosure of sexual abuse past the age of 12 years, of demographic, individual, and familial variables
and only 24.3% before the age of 6 years.16 was also illustrated in our normative sample. The
The decline in overt sexual behavior with age was significant inverse relationship with age was con-
confirmed in our normative sample when the total firmed with regression analysis. Maternal education
score on the CSBI was examined. Caregivers re-
is correlated significantly with sexual behavior, but
ported less overt sexual behavior in 10- to 12-year-
the gender of the child and the parental professional
old children in comparison with 2- to 5-year-old
status did not, which is similar to the findings for the
children. This decline does not seem to be a contin-
American samples. The relation of maternal educa-
uous phenomenon, but seems to occur in phases,
tion to increased reporting of behavior problems in
corresponding to preschool years (2–5 years), middle
children has been noted before, and Friedrich et al3,4
childhood (6 –9 years), and prepuberty (10 –12 years).
Analysis of the endorsement frequencies of the suggests that better educated parents may be in a
individual CSBI items enabled a more detailed de- position to be more observant of their children, thus
scription of the development of sexual behavior in 2- witnessing (sexual) behaviors that less observant or
to 12-year-old children. Although all the listed be- more occupied parents might miss.
haviors appear in the normative sample, there clearly Family nudity and parental attitudes regarding
existed certain behaviors that could be labeled as sexual curiosity of their child or concerning tolerance
more developmentally appropriate than others did. toward masturbation, homosexuality, or extramari-
For preschool children these include: “touches sex tal sex, were also significantly correlated to the re-
parts in public or at home,” “touches or tries to touch porting of sexual behavior of their children and ac-
mother’s breasts,” “undresses self in front of others,” counted for .10% of the explained variance, even
“kisses other children not in the family,” or “walks after removing the effect of age and gender of the
around without clothes or in underclothes.” In 6- to child, maternal education, and parental professional
9-year-old children, a number of these behaviors are status. This could reflect that the sexual behavior of
still endorsed by .20% of the population. Other children is influenced by the family environment in
behaviors tend to be more frequent in this age cate- which they are raised. A more liberal attitude regard-
gory; eg, “asks questions about sexuality” or “shy ing (childhood) sexuality, however, could be re-
about undressing”. Most items reflecting sexual cu- flected in a parent more willing to report sexual
riosity or preoccupation tend to increase with age behavior of their children, without influencing the
and are therefore relatively more frequent in the 10- behavior in itself. It seems reasonable to assume that
to 12-year-old age group. “Tries to look at picture of both mechanisms are responsible for this phenome-
(partially) nude people” and “talks about sex acts” non.
are two examples of behaviors that are infrequent in The relationship of other personal or familial vari-
the lower age group, but appear in .25% of the ables to the sexual behavior were less informative.
children older than 10 years. Separated or divorced parents seem to report higher
A number of behaviors are very unusual and were levels of sexual behavior in their children. Although
rarely endorsed in the three age categories. These the relationship is significant, it does not account for
behaviors tend to have high loadings on the same .1% of the explained variance in our normative
factor in the factor analysis, and are best labeled as sample. Similar observations were made for the
intrusive, aggressive, or more imitative of adult sex- number of children in the family (higher number

892 CHILD SEXUAL BEHAVIOR INVENTORY

Downloaded from www.pediatrics.org by on March 22, 2007
predicted lower frequencies of reported sexual be- ACKNOWLEDGMENTS
havior) and the victim status of the child concerning This study was supported by a grant to Eric Schoentjes from the
physical abuse (parents of physically-abused chil- Fund for Scientific Research–Flanders.
dren reported significant higher levels of sexual be- We thank Iris Leeman and Ilze Pastijn for their technical help;
Mimi Giri, Robert Vermeiren, and Elli Kruithof for their critical
havior), even after controlling for the effects of ma- review; and Johan Denollet and Monique Elseviers for their sta-
ternal education, parental professional status, and tistical advice.
age and gender of the child. More surprisingly, the
88 parents (9.6% of the respondents) who reported REFERENCES
that they themselves had been the victim of “adverse 1. Finkelhor D. Sexually Victimized Children. New York, NY: Free Press;
sexual experiences before the age of 16 years,” did 1979:20
2. Martinson FM. The Sexual Life of Children. Westport, CT: Bergin and
not report significantly different levels of sexual be- Garvey; 1994:8, 136
havior in their children. One would expect that their 3. Friedrich WN, Grambsch P, Broughton D, Kuiper J, Beilke, RL. Norma-
own experience would make them either more or tive sexual behavior in children. Pediatrics. 1991;88:456 – 464
less observant of the sexual behavior of their child, 4. Friedrich WN, Fisher J, Broughton D, Houston M, Shafran CR. Norma-
tive sexual behavior in children: a contemporary sample. Pediatrics.
but this could not be confirmed in our normative
1998;101(4). URL: http://www.pediatrics.org/cgi/content/full/101/
sample. 4/e9
Finally, sexual behavior was related to the other 5. Linblad F, Gustafsson PA, Larson I, Lundin B. Preschoolers’ sexual
reported general behavioral problems. Internalizing behavior at daycare centers: an epidemiological study. Child Abuse
behavior as well as externalizing behavior were sig- Neglect. 1995;19:569 –577
6. American Academy of Child and Adolescent Psychiatry. AACAP offi-
nificantly related to the sexual behavior and each cial action: practice parameters for the forensic evaluation of children
accounted for ;10% of the explained variance. This and adolescents who may have been physically or sexually abused.
finding is similar to that of previous studies and J Am Acad Child Adolesc Psychiatry. 1992;36:423– 442
suggests that children with manifest emotional or 7. Cosentino CE, Meyer-Bahlburg HF, Alpert JL, Weinberg SL, Gaines R.
Sexual behavior problems and psychopathology symptoms in sexually
behavioral problems tend to exhibit a broader range
abused girls. J Am Acad Child Adolesc Psychiatry. 1995;34:1033–1042
of behaviors, including excessive sexual behavior. 8. Friedrich WN, Grambsch P, Damon L. Child sexual behavior inventory.
This description of sexual behavior in a normative Normative and clinical comparisons. Psychol Assess. 1992;4:303–311
sample of Dutch-speaking 2- to 12-year-old children 9. Cohen JA, Mannarino AP. A treatment study for sexually abused pre-
confirms earlier findings in this field. A variety of school children: outcome during a one-year follow-up. J Am Acad Child
Adolesc Psychiatry. 1997;3:1228 –1235
sexual behaviors seems to be normal and their oc- 10. Gordon BN, Schroeder CS. Sexuality: Developmental Approach to Problems.
currence tends to be age-dependent. Information New York, NY: Plenum Press; 1995:77
concerning age-appropriate sexual behavior allows 11. Bates JE. Parents as scientific observers of their children’s development.
pediatricians to provide better counseling to parents In: Friedman SL, Haywood HC, eds. Developmental Follow-up: Concepts,
Domains, and Methods. San Diego, CA: Academic Press; 1994:197–215
or other caregivers more adequately concerning the
12. Oostveen JM, Meulmeester JF, Cohen-Kettenis PT. Seksueel gedrag van
normality of a large number of sexual behaviors in kleuters (English translation: Sexual behavior of preschool children).
children. Unusual sexual behaviors like intrusive or Nederlands tijdschrift voor Geneeskunde 1994;138:2200 –2204
aggressive sexual behaviors, or highly increased sex- 13. Cohen-Kettenis PT, Sandfort T. Seksueel gedrag van kinderen: een
ual behavior, should warn the pediatrician of the kwantitatief onderzoek onder moeders (English translation: Sexual be-
havior of children: quantitative research using mother’s reports). Tijd-
possibility of other behavioral or emotional prob- schrift voor seksuologie, 1996;20:254 –265
lems, including the possibility of sexual abuse.8,17 On 14. Friedrich WN, Berliner L, Butler J, Cohen J, Damon L, Shafran C. Child
the other hand, unfounded labeling of age-appropri- sexual behavior: un update with the CCSBI-3. APSAC Advisor. 1996;9:
ate sexual behavior as abnormal or harassing, can 13–14
15. Achenbach TM, Edelbrock C. Manual for the Child Behavior Checklist and
have detrimental effects on the child.2 The impor-
Revised Child Behavior Profile. Burlington, VT: University of Vermont;
tance of taking familial variables into account when 1983
assessing the sexual behavior of a child should also 16. Willems G. Meldingen van Kindermishandeling: Cliëntenregistratie bij de
be stressed, mainly as the result of the strong influ- Vertrouwenscentra Kindermishandeling, rapport 1997 (English translation:
ence of environmental factors on the (reporting of) Reporting of Child Abuse: Registration in the Child Protection Agencies,
Report 1997). Brussels, Belgium: Kind en Gezin; 1998
sexual behavior in children. The ability to refer to a 17. Kendall-Tacket KA, Williams LM, Finkelhor D. Impact of sexual abuse
culturally relevant normative sample is likely to be on children: a review and synthesis of recent empirical studies. Psychol
advantageous for optimal counseling. Bull. 1993;113:164 –180

ARTICLES 893
Downloaded from www.pediatrics.org by on March 22, 2007
 Child Sexual Behavior Inventory: A Dutch-speaking Normative Sample
Eric Schoentjes, Dirk Deboutte and William Friedrich
Pediatrics 1999;104;885-893
DOI: 10.1542/peds.104.4.885
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