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Cerebral palsy (CP) is the most common childhood motor disability. The Center for Disease Control and Prevention (CDC) reports prevalence between 1.5-4 per 1,000 children worldwide, and between 3.1-3.6 per 1,000 children in the United States.

April 1997 became a pivotal month when the article on the development of the Gross Motor Functional Classification System (GMFCS) was published. With the eventual adoption of the GMFCS by researchers and rehabilitation professionals working with individuals with CP, other classification systems were developed. These include the Manual Ability Classification System (MACS), Communication Function Classification System (CFCS), and the Eating and Drinking Ability Classification System (EDACS).

This week I put them all together in one infographic as a quick reference for rehabilitation professionals, educators and families. I will also discuss how functional classifications are helpful in school-based practice, and provide you with the information and resources for each.

Utilizing the Functional Classification Systems

There are a few things to keep in mind when using these classification systems:

  1. The 5 levels in each classification system are broad categories that represent “clinically meaningful distinctions” in function. They are not detailed assessments of function. When limitation is noted with any of these classification systems, it is recommended that you utilize additional assessment tools to determine specific information on performance or impairments that impact the child’s ability to participate in school.
  2. These classifications rate performance, not capacity. While capacity is the best that the child can do, performance refers to what the child usually does in his or her current environment.
  3. The scales used by the classification systems are not ordinal. Although they distinguish different levels of function, the distances between levels (in terms of performance) are not equal. Neither are individuals with CP distributed evenly across the 5 levels of each classification system.
  4. Each classification system should be rated independently. In many cases, the child will have different levels under each classification system. For example, a child with a GMFCS Level II may have a MACS Level III, a CFCS Level IV and an EDACS Level I. Hidecker et al (2012) found that among 222 children with CP, only 36 or 16% had the same GMFCS, MACS and CFCS levels (EDACS was not included in this study). Compagnone et al (2014) found that strong correlation among the GMFCS, MACS and CFCS was limited to those classified as Level V – i.e., a child with severe disabilities due to CP is likely to have the lowest levels of mobility, manual and communication skills.
  5. If you are undecided when classifying between 2 levels, refer to the instructions for specific guidance. At times, there may be no clear choice. In fact, if you look at the motor growth curves for each GMFCS level, you can see a wide range of abilities within each level that appear to overlap with those of the next lower or higher level. For example, you may think that a child is either functioning in the higher percentiles of GMFCS Level IV or in the lower percentiles of GMFCS Level III. In cases like this, choose the level that best fit the child’s everyday function and record the reason for your decision for clarification and future reference.

Applying the Functional Classification Systems

The GMFCS and MACS are predictive measures, they should not be used as outcome measures

  • Research studies on the GMFCS and the MACS have shown the stability of their levels over time. Thus, they are good prognostication tools. A child who was classified as GMFCS Level IV before his/her 2nd birthday, for example, will likely still be at Level IV at age 12. This information, though sobering, can be used now to plan and address the child’s current and possible future needs. An early introduction of power mobility for this child can address current mobility needs, while also ensuring that he/she achieves proficiency using the device that will likely still be needed at age 12. Likewise, a classification of MACS Level III can lead to exploration of compensatory strategies that can facilitate handling abilities now and in the future.
  • Since the GMFCS and MACS levels are generally stable, they are not good outcome measures. To capture changes in performance, choose additional tests.

CFCS and EDACS are not predictive, and may be used as outcome measures

  • On the other hand, no study has demonstrated the stability of either the CFCS or the EDACS. So, they should not be used for prognostication.
  • As  such, they may be currently used as outcome measures. But, since the descriptions of the CFCS and EDACS levels are broad, they may still not be sensitive enough to capture small changes in function. So, you may want to use additional, more detailed tests and measures to complement the CFCS or EDACs in monitoring progress.

Use all 4 classification systems for better communication and collaboration

  • It is highly recommended to use all 4 classification systems to provide a comprehensive picture of the child’s overall function.
  • If the whole team adopts their use, the team will also gain a common language, and a similar awareness or knowledge of the child’s abilities. This can then become a basis for collaboration, from assessment, to goal setting, and implementing coordinated interventions for the child.

Planning interventions

  • Since the classification systems capture the child’s general function, they are great tools for planning interventions.
  • You can implement compensatory strategies that provide the child the ability to be independent right away (e.g., mobility devices, adaptive utensils for eating, communication devices).
  • You can also design remediation interventions that can help the child improve their function (e.g., swallowing techniques) or to prevent secondary impairments (e.g., flexibility, strengthening and aerobic exercises). Since the GMFCS and MACS are predictive, the team can also prognosticate, establish feasible goals and determine remediation strategies that can make meaningful changes in the child’s ability to participate in school, at home and in the community.

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Here are some basic information and resources for the 4 classification systems:

Gross Motor Functional Classification System (GMFCS)

The Basics

  • The GMFCS was developed to classify mobility of individuals with CP.
  • It includes 5 Levels:
    • LEVEL I – Walks without Limitations
    • LEVEL II – Walks with Limitations
    • LEVEL III – Walks Using a Hand-Held Mobility Device
    • LEVEL IV – Self-Mobility with Limitations; May Use Powered Mobility
    • LEVEL V – Transported in a Manual Wheelchair
  • The instructions are available here: Gross Motor Classification System – Expanded & Revised (GMFCS – E&R). I recommend that you read it, and keep it handy.
    • To further facilitate correct classification, it describes distinctions between levels that are next to each other (e.g., Level I vs. Level II, Level II vs. Level III, etc.)
    • It includes descriptors for each level under 5 age groups:
      • Before 2nd Birthday
      • Between 2nd & 4th Birthday
      • Between 4th & 6th Birthday
      • Between 6th & 12th Birthday
      • Between 12th & 18th Birthday
  • Classification can be done by the medical professional. The family can also determine the classification using a family questionnaire. Better yet, the medical professional can collaborate with the parent to make the determination.

Select Research

The GMFCS has been used in multiple research into cerebral palsy. Here are some of the interesting findings in the past years:

  • Hanna et al (2008) found a decline in function for children classified as Levels III-V starting at age 7 or 8 years old. Thus, it is important to minimize secondary impairments that may occur with age.
  • Palisano et al (2010) described the probability of walking, wheeled mobility and assisted mobility among the 5 levels.
  • Josenby et al (2011) found improved motor function, that also impacted GMFCS levels after dorsal rhizotomy.


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Manual Ability Classification System (MACS)

The Basics

  • The MACS describes how a child usually uses his/her hands to handle objects in the home, school, and community settings
  • It includes 5 Levels:
    • LEVEL I – Handles objects easily and successfully
    • LEVEL II – Handles most objects but with somewhat reduced quality and/or speed of achievement
    • LEVEL III – Handles objects with difficulty; needs help to prepare and/or modify activities
    • LEVEL IV – Handles a limited selection of easily managed objects in adapted situations
    • LEVEL V – Does not handle objects and has severely limited ability to perform even simple actions
  • The instructions and distinctions among the levels are available here.
  • Classifications can be done by a medical professional, educator, parent or child.
  • You can also read SeekFreaks Article Review on the stability of the MACS.


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Communication Function Classification System (CFCS)

The Basics

  • The CFCS was initially developed to determine “everyday communication performance” of individuals with CP, as a complement to the GMFCS and the MACS. However, it is currently being used for individuals with any disabilities.
  • The communication method considered in classifying the individual is not limited to speech. It includes any other means of communication such as sign language, gestures, facial expressions, augmentative communication devices, and others.
  • It includes 5 Levels
    • LEVEL I – Sends and receives information with familiar and unfamiliar partners effectively and efficiently
    • LEVEL II – Sends and receives information with familiar and unfamiliar partners but may need extra time
    • LEVEL III – Sends and receives information with familiar partners effectively, but not with unfamiliar partners
    • LEVEL IV – Inconsistently sends and/or receives information even with familiar partners
    • LEVEL V – Seldom effectively sends and receives information even with familiar partners
  • The instructions, clarifications and level identification flowcharts are available here.
  • Classification can be performed by a medical professional, educators, parents, caregivers and individuals with CP.


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Eating and Drinking Ability Classification System (EDACS)

The Basics

  • The EDACS was developed to determine eating and drinking of individuals with CP in everyday life.
  • It includes 5 Levels
    • LEVEL I – Eats and drinks safely and efficiently
    • LEVEL II – Eats and drinks safely but with some limitations to efficiency
    • LEVEL III – Eats and drinks with some limitations to safety; there maybe limitations to efficiency
    • LEVEL IV – Eats and drinks with significant limitations to safety
    • LEVEL V – Unable to eat or drink safely – tube feeding may be considered to provide nutrition
  • The EDACS instructions may be downloaded from here. The algorithm is available here.
  • Classification was shown to be reliable when performed by speech and language therapists and parents.



Seeking Your Views

How many of these have you used with the team? Did it help with planning and prioritizing the child’s interventions?

Was it easy disclosing the results of the GMFCS and/or the MACS to the child’s family? Did you discuss prognostication with them and the team?

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Readers of this article also read:

10 Handy American Speech-Language-Hearing Association Resources

Article Review: Child-focused vs. Context-focused Intervention

Article Review: Do Teachers Know the Impact of Preterm Birth?

50 Alternatives to “Good Job!”

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