Most parents who hear the words “cerebral palsy” eventually become familiar with GMFCS, the five-level scale that describes how a child moves and walks. What fewer parents are told is that GMFCS is one of four major classification systems used in CP care. MACS describes hand use. CFCS describes communication. EDACS describes eating and drinking. Together, these four systems give the comprehensive functional picture that drives therapy goals, equipment decisions, IEP accommodations, and daily-life planning. This guide explains each system, walks through the levels, and shows how parents can use them practically.
Why Four Classifications, Not Just One
Cerebral palsy affects more than walking. A child with CP may have intact gross motor function but significant hand-use difficulty, or strong communication skills with severely impaired feeding. Using only GMFCS would miss most of what daily life is actually like for a CP child.
The four classifications were developed at different times by different research groups, but together they form a complementary set:
| System | What It Measures | Year Developed | Key Citation |
|---|---|---|---|
| GMFCS | Gross motor function (walking, sitting, transfers) | 1997 | Palisano et al., Developmental Medicine & Child Neurology |
| MACS | Hand use with objects in everyday situations | 2006 | Eliasson et al., Developmental Medicine & Child Neurology |
| CFCS | Effectiveness of everyday communication | 2011 | Hidecker et al., Developmental Medicine & Child Neurology |
| EDACS | Eating and drinking ability and safety | 2014 | Sellers et al., Developmental Medicine & Child Neurology |
Each uses the same five-level format (I most function, V most assistance needed), making them easy to remember and easy to communicate across professions and settings.
MACS: Manual Ability Classification System
MACS describes how children with CP handle objects in everyday situations: toys, utensils, school supplies, clothing, daily-living items. The five levels:
| MACS Level | Description |
|---|---|
| I | Handles objects easily and successfully. May have limitations with tasks requiring speed and accuracy. Independence with daily activities is largely unrestricted. |
| II | Handles most objects but with somewhat reduced quality and/or speed. May avoid certain activities. |
| III | Handles objects with difficulty; needs help to prepare and/or modify activities. Slower and limited success with object manipulation. |
| IV | Handles a limited selection of easily managed objects in adapted situations. Performs parts of activities with effort and limited success. |
| V | Does not handle objects and has severely limited ability to perform even simple actions. Requires total assistance. |
A version called Mini-MACS was developed for children aged 1 to 4, recognizing that hand-use development in younger children differs from older children. The Mini-MACS uses the same five-level structure but with age-appropriate descriptors.
CFCS: Communication Function Classification System
CFCS rates how effectively a child communicates in everyday situations, considering both sending and receiving messages, speed of communication, and whether the partner is familiar or unfamiliar. The five levels:
| CFCS Level | Description |
|---|---|
| I | Effective sender and effective receiver with both familiar and unfamiliar partners. Communication is comfortable across most everyday situations. |
| II | Effective sender and effective receiver, but with a slower pace. May need extra time but communication is comfortable with both familiar and unfamiliar partners. |
| III | Effective sender and effective receiver with familiar partners. Less effective with unfamiliar partners. |
| IV | Inconsistent sender and/or receiver, even with familiar partners. Communication occurs but is not consistent. |
| V | Seldom an effective sender or receiver, even with familiar partners. Communication is rarely successful. |
An important note: CFCS includes any form of communication, including speech, gestures, sign language, eye gaze, communication boards, and augmentative communication devices. A child using a speech-generating device effectively can be CFCS I or II. The system measures effectiveness of communication, not the method.
Functional classifications drive equipment authorizations, therapy frequency, and IEP services. Understanding them helps you advocate for what your child needs.
EDACS: Eating and Drinking Ability Classification System
EDACS describes how a child eats and drinks. Unlike the others, EDACS includes both an ability scale (I to V) and a separate level of assistance scale (independent, requires assistance, totally dependent), recognizing that eating ability and the assistance needed are partly independent. The five ability levels:
| EDACS Level | Description |
|---|---|
| I | Eats and drinks safely and efficiently with foods and drinks of typical textures. |
| II | Eats and drinks safely but with limitations to efficiency. May take longer and need more help to eat enough. |
| III | Eats and drinks with some limitations to safety; there may be limitations to efficiency. Requires modified textures. |
| IV | Eats and drinks with significant limitations to safety. Substantial modifications and possibly some non-oral feeding. |
| V | Unable to eat or drink safely. Tube feeding may be required for nutrition and hydration. |
EDACS is particularly useful in clinic and school settings because it directly informs feeding plans, school meal accommodations, and the decision about whether to consider supplemental tube feeding. The accompanying level-of-assistance scale captures the practical question of how much help is needed for the child to eat.
How These Classifications Compare to GMFCS
For reference, GMFCS describes:
| GMFCS Level | Description (school age) |
|---|---|
| I | Walks without limitations. |
| II | Walks with limitations (e.g., on uneven surfaces, long distances). |
| III | Walks using a hand-held mobility device (walker, crutches). |
| IV | Self-mobility with limitations; may use powered mobility. |
| V | Transported in a manual wheelchair. |
An important relationship: a child’s levels in different systems are not automatically the same. A child can be GMFCS V (transported in a wheelchair) but CFCS I (effective communicator with a device). A child can be MACS V but EDACS II. Each domain is rated separately because brain injury affects different motor and cognitive systems differently.
How classifications relate to specific equipment
Functional levels often translate directly into specific equipment recommendations and insurance authorizations. For mobility (GMFCS), levels I to II generally need orthotics or occasional walking aids; level III typically uses a walker or crutches; level IV often combines a manual wheelchair with some powered mobility; level V uses a manual wheelchair full-time, often with custom seating and head support. For hand use (MACS), levels I to II may benefit from adaptive utensils and writing aids; level III often needs adapted positioning and modified tools; levels IV to V typically need significant adaptive equipment and caregiver assistance. For communication (CFCS), levels III to V often qualify for evaluation for an augmentative and alternative communication (AAC) device, which insurers generally authorize when the right level documentation is provided. For eating (EDACS), levels III to IV often need modified textures and seating; level V is the level at which tube feeding is most often used. Knowing the levels helps families and clinicians articulate the equipment justifications insurers require.
Whether levels change in adolescence and adulthood
Functional classification levels are designed to be stable from age 2 through childhood, and most levels do remain stable. However, some children show meaningful changes in adolescence or adulthood that are worth knowing about. Gross motor function (GMFCS) sometimes declines in adolescence in children at GMFCS levels III to V, particularly if contractures, weight gain, or pain reduces functional walking. Hand use (MACS) can improve with continued therapy through adolescence, particularly when adaptive techniques and equipment open new possibilities. Communication (CFCS) often improves as children become fluent users of AAC devices. Eating (EDACS) can shift in either direction depending on overall health, weight, and motor changes. Reassessment in adolescence is reasonable, especially when planning the transition from pediatric to adult care. Adult care providers often use the same scales, which makes communication smoother across this transition.
Common misunderstandings about the levels
A few clarifications that help when reading clinic notes or discussing classifications with school staff. The levels are not severity grades in the colloquial sense. A child at GMFCS V may have intact cognition; a child at GMFCS II may have significant cognitive differences. Don’t read mobility level as a proxy for overall ability. The levels describe habitual function, not best performance. A child who can walk short distances at home (best performance) but uses a wheelchair at school for long distances and safety (habitual function) is rated based on the wheelchair use. The levels do not predict outcomes for individual children. They describe current function. A GMFCS III child may make significant gains with therapy or, conversely, experience decline in adolescence. Different professionals may rate the same child differently. Inter-rater agreement is generally good but not perfect, particularly between adjacent levels. The most accurate rating is usually the one done by the professional who knows the child’s habitual function best.
How Parents Use These Classifications Practically
Functional classifications appear throughout your child’s care and can be a powerful advocacy tool when you understand them:
What about the Visual Function Classification System (V-FCS)?
A fifth classification, the Visual Function Classification System (V-FCS), was developed to describe everyday visual function in children with CP. It uses the same five-level format as the others. V-FCS is less widely used in routine practice but is gaining recognition, particularly for children with cortical visual impairment (CVI), which is common in children with extensive brain injury. If your child has CVI or significant visual concerns, ask your ophthalmologist or pediatric neurologist whether V-FCS classification has been or should be assigned. Like the other systems, V-FCS gives a shorthand that travels with the child across settings.
Asking your team for the levels
If you do not know your child’s GMFCS, MACS, CFCS, and EDACS levels, ask. They may already be documented in clinic notes but not communicated explicitly. Reasonable questions: “What is my child’s GMFCS level?” “Has anyone assigned MACS, CFCS, or EDACS?” “Who would assign these?” If your child sees a comprehensive CP clinic, all four are typically documented; if your child sees specialists separately, the levels may be in different notes. Bringing the four levels together in one summary (often in a parent-held notebook or care plan) is one of the most useful things parents can do for ongoing care.
The four classification levels translate directly into specific accommodations and services. We can help you understand how to use them effectively.
Related reading for parents
- Ataxic cerebral palsy: understanding balance and coordination challenges
- Mixed cerebral palsy: when a child has symptoms of more than one CP type
- Genetic causes of cerebral palsy: when CP isn’t caused by birth injury
- Conditions that mimic cerebral palsy: differential diagnosis parents should know
- Basal ganglia injury on an HIE MRI: what this finding means for your child
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