The Manual Ability
children. It has been defined as ‘a disorder of movement and
Classification System
(MACS) for children
with cerebral palsy:
scale development and
evidence of validity
and reliability
Ann-Christin Eliasson* PhD OT;
Lena Krumlinde-Sundholm PhD OT, Department of Woman
and Child Health, Karolinska Institute, Stockholm;
Birgit Rösblad PhD PT, Department of Community Medicine
and Rehabilitation, University of Umeå, Umeå;
Eva Beckung PhD PT, Queen Silvia Children’s Hospital,
Göteborg;
Marianne Arner PhD MD, Hand Unit, Department of
Orthopaedics, Lund University Hospital, Lund;
Ann-Marie Öhrvall MSc OT, Department of Habilitation,
Stockholm County Council, Stockholm, Sweden;
Peter Rosenbaum MD FRCP, CanChild Centre for Childhood
Disability Research, McMaster University, Hamilton,
Ontario, Canada.
*Correspondence to first author at Neuropaediatric
Research Unit Q2:07, Astrid Lindgren Children’s Hospital,
SE-171 76 Stockholm, Sweden.
E-mail: ann-christin.eliasson@kbh.ki.se
The Manual Ability Classification System (MACS) has been
developed to classify how children with cerebral palsy (CP) use
their hands when handling objects in daily activities. The
classification is designed to reflect the child’s typical manual
performance, not the child’s maximal capacity. It classifies the
collaborative use of both hands together. Validation was based
on the experience within an expert group, a review of the
literature, and thorough analysis of children across a spectrum
of function. Discussions continued until consensus was reached,
first about the constructs, then about the content of the five
levels. Parents and therapists were interviewed about the
content and the description of levels. Reliability was tested
between pairs of therapists for 168 children (70 females, 98
males; with hemiplegia [n=52], diplegia [n=70], tetraplegia
[n=19], ataxia [n=6], dyskinesia [n=19], and unspecified CP
[n=2]) between 4 and 18 years and between 25 parents and
their children’s therapists. The results demonstrated that MACS
has good validity and reliability. The intraclass correlation
coefficient between therapists was 0.97 (95% confidence
interval 0.96–0.98), and between parents and therapist was 0.96
(0.89–0.98), indicating excellent agreement.
Developmental Medicine & Child Neurology 2006, 48: 549–554 549
Cerebral palsy (CP) is the most common neurodisability in
posture due to a defect or lesion of the immature brain’ (Bax
1964) and as ‘a group of non-progressive, but often changing
motor impairment syndromes secondary to lesions or anom-
alies of the brain arising in the early stages of development’
(Mutch et al. 1992). A proposed new definition of CP focuses
on a broader perspective of activity restriction and disability
(Bax et al. 2005). Classification of subtypes of CP has been pro-
posed based on location of the lesion, part of the body involved,
or degree of impairment (Ingram 1964). However, none of
these descriptions provides information about the child’s func-
tional abilities in daily life. One recent classification with a clear
functional approach is the Gross Motor Function Classification
System (GMFCS; Palisano et al. 1997). The GMFCS describes
gross motor function in terms of self-initiated movements
with emphasis on function in sitting and walking. This classi-
fication is based on the concept of disability (World Health
Organization 1980) and of functional limitation (National
Institutes of Health 1993). The GMFCS has been widely adopt-
ed internationally, suggesting that it has filled a gap in func-
tional classification (Morris and Bartlett 2004). No similar
classification of hand function has been available, but one is
needed to broaden the functional perspective of CP beyond
gross motor issues.
Classification is the process of grouping data, persons, or
objects into classes according to common characteristics,
thereby reducing the number of data elements. The usefulness
of a classification depends on how understandable and clear
the descriptions are, and how meaningful different levels are.
The most common way to classify hand function in CP has
been to use terms like ‘mild’, ‘moderate’, and ‘severe’ impair-
ment (Claeys et al. 1983). Although some other classifica-
tions are available (House et al. 1981, Zancolli and Zancolli
1981, Krägeloh-Mann et al. 1993, Beckung and Hagberg 2002),
all of them classify aspects of grasping rather than functional
performance and none has been tested for reliability.
This proposed new classification, the Manual Ability
Classification System (MACS), is designed to classify how chil-
dren with CP use their hands when handling objects in daily
activities. The focus is on manual ability, as defined in the
International Classification of Functioning, Disability and
Health (ICF; World Health Organization 2001). It has its start-
ing point in upper limb function but is also influenced by envi-
ronmental, personal, and contextual factors. MACS follows
Penta and coworkers’ definition of manual ability as ‘the capac-
ity to manage daily activities that require the use of the upper
limbs, whatever the strategies involved, which can be observed
from activity performance in the person’s everyday context’
(Penta et al. 2001). MACS is not designed to classify best capaci-
ty and does not mean to distinguish different capacities
between hands. MACS reports the collaboration of both hands
together: it is not an assessment of each hand separately. It
looks for the children’s manual ability to ‘handle object(s) in
daily life’. By that we mean those activities that are relevant and
age appropriate for the child including, for example, eating,
dressing, playing, writing, etc.; these are distinct from
advanced skilled activities that require special training for per-
formance, such as playing a musical instrument. Neither does it
classify activities closely related to academic skills in school.
The emphasis of MACS is on handling objects in an individual’s
personal space, the space immediately close to one’s body, as
distinct from objects that are not within reach, thus minimizing
the potential confounding influence of limitations in gross
motor function. Distinctions between the levels are based on
the child’s ability to handle objects, i.e. the quantity and quality
of performance and need for assistance or adaptations to per-
form manual tasks in everyday life.
The aims of this report are to describe the development
of MACS and provide evidence of its validity and reliability.
Efforts were made to follow recommendations about accu-
mulating evidence for scale validity according to guidelines
published in Standards for Educational and Psychological
Testing (American Educational Research Association 1999).
environments, mainly in their homes or schools. Using those
videos, we discussed and defined the classification levels based
on the assumption that five levels would be suitable, if possi-
ble, to correspond to the structure of GMFCS. To reduce the
complexity of the work we agreed to start by developing a
classification suitable for children aged 8 to 12 years. We have
worked with a Swedish and an English language version of
the classification in parallel.
The study was conducted after approval from the Ethics
Research Committee at the Karolinska Hospital, Sweden, and
the State Government, Victoria, Australia. Informed consent
was obtained from the parents of the children.

Method External processes for validation

PROCESSES OF DEVELOPMENT AND VALIDATION OF THE
CLASSIFICATION
The first step in developing MACS was to assemble an expert
group, comprising six people (two occupational therapists,
two physical therapists, one hand surgeon, and one develop-
mental paediatrician), each with over 20 years of clinical
experience and research in paediatric rehabilitation. It was
considered important to involve people from different pro-
fessional backgrounds and experience of research (Fink et al.
1984). The work in the expert group has proceeded through
workshops, telephone conferences, and e-mail contacts for
more than 3 years, with the construct development of the
classification as an ongoing process. First, an inventory of
available tests and classifications of hand function was con-
structed. An essential next step was to clarify the conceptual
background and to define and formulate the basic underlying
construct. Discussions occurred until consensus was reached
in the expert group.
It then became important to describe the content of the
different levels of the classification. We video recorded chil-
dren with different subtypes of CP and fields of functioning
when performing various manual activities in their natural
Table I: Distribution of children by age and by Gross Motor
Function Classification System (GMFCS) levels (n=164)
Age (y) n GMFCS levels
I II III IV
When the first version of the classification was outlined an
external validation process was initiated, by involving profes-
sionals within paediatric rehabilitation and parents of children
with CP. To collect opinions from professionals we presented
preliminary versions of the classification at national and inter-
national conferences (Sweden 2002, Canada 2003, Norway
2003). Interactive poster presentations were used where the
participants were encouraged to classify children from video
clips and to comment on the classification. Oral presenta-
tions were also given after which the audience was invited to
discuss and offer feedback. Comments and suggestions col-
lected on these occasions were brought back to the expert
group and processed. The refinement of the wording and
the distinctions between levels was a continuous process
until the reliability study started.
An additional step for validity testing was to investigate if
this concept was meaningful for parents of children with CP
(Öhrvall 2005). After a brief introduction, 25 parents classi-
fied their child according to the MACS leaflet (Appendix I).
Thereafter, each parent participated in a semi-structured tape-
recorded interview following an interview guide (Kvale 1996).
The questions focused on the parents’ thoughts about the
classification. They were asked if this concept was meaning-
ful for describing their child’s hand function. They were then
asked for their rationale for choosing a particular level instead
of others. A third set of questions concerned their judgement
of the overall usefulness of the classification. The same pro-
cedure was repeated with the child’s occupational therapist
or, sometimes, physiotherapist.
V

4 8 3 2 – – 3 Data processing of the interviews

5 15 3 4 1 2 5 Textual analysis of the materials from parents and therapists
6 10a 2 2 3 2 – was performed separately (Kvale 1996), based on the three
7 12 1 4 2 3 2 sets of questions, and for each level of MACS. The remarks
8 16 9 1 1 3 2 were analyzed to understand if the distinction between lev-
9 13 4 3 5 1 – els was apparent or not (Polit and Hungler 1995).
10 29 9 2 6 7 5
11 16 4 4 4 1 3 PROCESS OF TESTING THE RELIABILITY OF THE CLASSIFICATION
12 16 5 5 – 5 1
Design
13 3 2 – – 1 –
Interrater reliability was studied by asking pairs of therapists
14 7 1 2 3 1 –
15 10 – 2 2 4 2 to classify the same child, and by asking parents and thera-
16 4 2 1 – – 1 pists to classify the same child. This meant that several thera-
17 3 1 – – – 2 pists classified more than one child whereas each child was
18 6a – – 1 2 – classified only once by each therapist.
Total 168 (164) 47 32 28 32 26 The parents and almost all therapists received a brief intro-
Per cent – 28 20 17 20 16 duction to MACS with the MACS leaflet, which they were
aGMFCS level missing for one child at 6y and three children at 18y.
encouraged to read thoroughly (Appendix I). They were also
invited to discuss uncertainties with the classification and

550 Developmental Medicine & Child Neurology 2006, 48: 549–554

rating procedure with someone from the expert group before
actually rating the children.
Procedure and participants
As originally planned, we started by classifying children aged
between 8 and 12 years. During the process of developing
MACS we frequently received comments from parents as well
as therapists that the classification could be valid for children
at other ages as well. We decided therefore to include chil-
dren between 4 and 18 years in the reliability testing. In total
168 children between 4 and 18 years (98 males, 70 females)
were classified by 93 therapists from six cities in Sweden and
one city in Australia (Table I). The severity of disability, accord-
ing to GMFCS, varies, as do the subtypes of CP (Tables I and II).
The Swedish classification of CP subtypes was used (Hagberg
and Hagberg 1993).
Interrater reliability between therapists for children aged
4 to 18 years
The 168 children were classified independently by two thera-
pists (Table III). Twenty children from Melbourne, Australia,
were analyzed first and separately to control for cultural dif-
ferences, and were then included in further calculations.
Interrater reliability between parents and therapists
Twenty-five children between 8 and 12 years were classified
independently by their parents and one therapist, in most cases
an occupational therapist. The children were selected to cover
what we assumed would be a wide range of functional abili-
ties, with the intention of representing all levels of MACS.
seemed to be related to the interpretation of certain words,
for example ‘independence’. One parent emphasized that
the child was independent in simple tasks, whereas the ther-
apist thought about activities that were more complex where
the child needed continuous support.
When discussing the overall usefulness of the classification,
parents suggested that MACS could be used for several purpos-
es: e.g., in contact with the social services and local council to
discuss the need for support and personal assistance; as infor-
mation for parents of infants with CP; for newly employed staff
working with the child; and as information between pro-
fessionals working with the same person. The therapists
expressed similar ideas but also emphasized the ability to use
MACS in the clinic for planning of treatment and goal setting.
INTERRATER RELIABILITY BETWEEN THERAPISTS
The classifications of 168 children between 4 and 18 years
were analyzed. ICC was 0.97 (95% confidence interval [CI]
0.96–0.98) for the whole group, indicating excellent agree-
ment (Table III). The total agreement was 84.5%. When ICC
was calculated for the different ages, there were similar
results (Table IV). A group of 20 children from Australia was
included. When this group was analyzed separately no differ-
ences in the understanding of the MACS were found; howev-
er, ICC was slightly lower at 0.91 (95% CI 0.77–0.96).
INTERRATER RELIABILITY BETWEEN PARENTS AND THERAPISTS
ICC between parents and therapists was 0.96 (95% CI 0.89–
0.98), indicating excellent agreement for the 25 children

Statistics
For analysis of interrater reliability a one-way random effects Table II: Types of cerebral palsy (CP) by Manual Ability
model (referred to as intraclass correlation coefficient [ICC] Classification System (MACS) rating by professionals
1) was used, which, according to Shrout and Fleiss (1979), is
suitable when different raters are assessing the children using Type of CP MACS levels
I II III IV V Total %
average measures. The ICC result is equivalent to a weighted
kappa (Fleiss and Cohen 1973). Rater agreement, the coeffi- Hemiplegia 10 38 4 – – 52 31
cient of total agreement between therapists (number of chil- Diplegia 12 23 18 15 2 70 42
dren with total agreement divided by total number of children; Tetraplegia/quadriplegia – – 1 9 9 19 12
Polit and Hungler 1994) was calculated. For descriptive analy- Ataxia 1 2 2 1 – 6 4
sis, the result from the first rater of MACS was used. For cor- Dyskinetic CP – – 3 4 12 19 12
relation between MACS and GMFCS, Spearman’s rank corre- Total 23 63 28 29 23 166a –
lation was used. % 14 38 17 17 14 – –
aCP type was unavailable for two children.
Results
VALIDATION OF THE CLASSIFICATION
All parents and therapists responded positively to the ques-
tion about whether MACS was built on a useful construct for Table III: Numbers of children 4 to 18 years in each Manual
describing the child’s hand function. They also found the dif- Ability Classification System level as rated by two therapistsa
ferences between the five levels meaningful and easy to under-
Therapist 2
stand. Parents emphasized the advantage of describing what
I II III IV V Total
the children actually can do instead of focusing on their limi-
tations. The distinction between capacity and performance Therapist 1
did not cause confusion for the families. Several therapists I 19 4 – – – 23
also emphasized that MACS was giving a structure to their II 2 56 6 – – 64
thinking, and that it was important to have one classification III – 5 22 1 – 28
for all kinds of CP. IV – 1 3 22 3 29
V – – – 1 23 24
The rationale for choosing a particular level instead of
Total 21 66 31 24 26 168
others was most often clear for both parents and therapists.
Although parents and therapists mainly agreed about the lev- aIntraclass correlation coefficient=0.97 (95% CI 0.96–0.98).

els there were some disagreements (reported below). These Numbers in bold represent total agreement.

Manual Ability Classification System for Children with CP Ann-Christin Eliasson et al. 551
between 8 and 12 years. The total agreement was 72%. There DISTRIBUTION OF MACS LEVELS AMONG SUBTYPES OF CP
was disagreement about one level for seven children, five of Children with all different subtypes of CP were included in
whom were rated on a higher level by the parents and two by the study (Table II, Fig. 1). The children with hemiplegia
the therapists. The disagreement was distributed across all were mainly seen in Level II but also in Levels I and III.
levels of MACS. Children with diplegia were found in Levels I to IV, whereas
children with dyskinetic CP and tetra- or quadriplegia were
apparent in Levels IV to V.
Table IV: Distribution of intraclass correlation coefficient
RELATION BETWEEN MACS AND GMFCS
(ICC) for different age groups
The correlation between GMFCS and MACS was 0.79 (p<0.05;
Age (y) n ICC (95% CI) Table V), with complete agreement in 49%. A large variation
occured at MACS Level II, where 40% of the children were
4–7 45 0.98 (0.97–0.99)
scored and where the agreement between GMFCS and MACS
8–12 90 0.96 (0.94–0.98)
was just 35%. Differences were also observed in the other levels
13–18 33 0.98 (0.96–0.99)
All: 4–18 168 0.97 (0.96–0.98) (Fig. 2).

CI, confidence interval. Discussion

MACS provides a new perspective for classifying manual ability
in children and adolescents with CP. As judged by parents of
Table V: Correlation between Manual Ability Classification children with CP and health professionals, MACS was based on
System (MACS) and Gross Motor Function Classification a valid construct. The classification looks at activities and gives
System (GMFCS) level ratingsa a single ‘level’ for the collaborative use of both hands when
MACS levels
handling objects in daily life. Parents and therapists perceived
I II III IV V Total the classification as a meaningful description of variations in
manual ability and felt confident when using MACS. Interrater
GMFCS levels reliability between the parent and therapist as well as between
I 15 29 2 – – 46 therapists was excellent; interrater reliability for different age
II 3 22 7 – – 32 groups was equally good. The results of testing with the
III 5 10 9 4 – 28 English version in Australia, although involving only a small
IV – 2 9 17 4 32
group of children, did not differ from the Swedish version,
V – – – 6 20 26
Totalb 23 63 27 27 24 164
indicating that linguistic or cultural differences do not affect
the outcome of MACS.
aSpearman’s correlation coefficient r=0.79. bGMFCS missing for During the process of constructing MACS several problems
four children. Numbers in bold represent total agreement. were identified. Commonly parents reported that the child

100 100

90 90

80 80

70 70

60 60
Per cent

Per cent

50 50

40 40

30 30

20 20

10 10

0 0
I II III IV V I II III IV V
MACS levels MACS levels

Diplegia Ataxia Dys CP GMFCS II GMFCS IV GMFCS V

Hemiplegia Tetra/quadri GMFCS I GMFCS III

Figure 1: Distribution of children (per cent of collected Figure 2: Distribution of children between levels of Manual
material) according to subtypes of cerebral paresis (CP). Ability Classification System (MACS) and Gross Motor
MACS, Manual Ability Classification System; dys, dystonia; Function Classification System (GMFCS).
tetra, tetraplegia; quadri, quadriplegia.

552 Developmental Medicine & Child Neurology 2006, 48: 549–554

could achieve a lot when they were motivated. Other com-
ments were that some children required frequent support
from adults to initiate activity and to find strategies and solu-
tions to problems. This highlights the complexity of manual
ability during task performance. There is a motor–cognitive
skill dimension in almost all tasks, with the cognitive part
involving ‘knowing what to do’ and the motor part involving
‘doing it correctly’ (Exner and Henderson 1995). Note, how-
ever, that when scoring MACS the reason for limited perfor-
mance (not handling objects) is not the investigated goal; rather
MACS should be scored based on what the children actually
do. This means, for example, when classifying children with
hemiplegia, it is their ability to perform the task, indepen-
dent of whether they use one or two hands, independent of
poor or good sensibility, that is classified. Gross motor func-
tion is also likely to influence the ability to handle objects,
especially in situations that require the child to move to
another location in the room or to bend to retrieve the
object. To minimize the influence of gross motor function on
the scoring on MACS we limited the classification to situa-
tions in which the objects to be handled were within reach of
the child.
A third problem identified and addressed was that of age.
The MACS takes into consideration that children’s ability to
handle objects increases with age. Hence, older children are
expected to achieve more difficult tasks. However, this was
mainly discussed as a problem in the expert group; it did not
apparently affect the classifications made by families and
therapists. Data collection started in the 8 to 12 year age
group, when most of the basic ‘normal development’ would
usually have occurred. When starting to use MACS for other
ages the term ‘age-related’ was incorporated into the classifi-
cation. Obviously, children handle different objects at 4 years
compared with adolescent age (e.g. fragile or sharp objects),
but this seemed obvious to people when deciding about
MACS levels. Likewise the word ‘independence’ needs to be
used in an age-related perspective, because a young child
needs more help and supervision than an older one.
So far we have not investigated the stability of the classifica-
tion over time, but our expectation is that most children will
stay at the same level. However, it is important to note that we
expect that as children get older they will develop, learn to han-
dle additional objects, and perform new age-related activities,
even if their relative functional characteristics are such that they
handle objects as described in that MACS level. There will prob-
ably be some instability of levels in the youngest age groups as
described earlier for the GMFCS (Wood and Rosenbaum
2000), and the interrater reliability may be lower for these
young children (Palisano et al. 1997). Knowledge of typical
development of hand function in children with CP would have
been useful when creating MACS but that has not, to our
knowledge, been described in the literature. A study collecting
longitudinal data with MACS is urgently needed.
MACS is reliable, both between therapists and between
parents and therapists. Disagreements were distributed across
all levels, indicating that none of the levels was more difficult
to judge than others. In all but one case, differences between
observers were only one level. The therapists taking part in
the study were recruited by an open invitation, which meant
that they had different degrees of experience in paediatrics,
from less than 1 year to more than 25 years. Most received
verbal information about the concept and ratings whereas
Manual Ability Classification System for Children with CP Ann-Christin Eliasson et al. 553
some had just read the leaflet. The selection of children was
also based on convenience, but it seems to reflect the pattern
of children with CP described in epidemiological studies. The
distribution of subtypes of CP agreed fairly well with earlier
reports (Hagberg and Hagberg 1993). This heterogeneous
sample of raters and children demonstrates the applicability
of MACS and strengthens the generalizability of the results so
far as they reflect community realities.
CP affects the whole body to a variable extent (Beckung and
Hagberg 2002). Limitation of activity associated with gross
motor function can be classified by GMFCS, whereas a reliable
and valid classification for limitation of activity related to manu-
al ability has not been available until now. Accordingly, the rela-
tion between gross and fine motor function is unclear. The
high but not perfect correlation between MACS and GMFCS in
the present study indicates that MACS is built on a different
construct to GMFCS. In only half of the children was there
exact agreement between MACS and GMFCS levels. This sug-
gests that gross and fine motor function in children with CP do
not neatly run in parallel, and can and should be independent-
ly classified. Hand function classified by Bimanual Fine Motor
Function and GMFCS has earlier shown different development
(Beckung and Hagberg 2002). The distribution of children
belonging to different levels of GMFCS was fairly even (18–22%
for all levels) whereas 40% of the children belonged to Level II
in MACS. Noteworthy also was that the lowest proportion of
children were classified in Level I. This distribution of MACS
levels may highlight hidden problems of manual activity limita-
tion in children with CP and needs further investigation. MACS
did not correspond to subtypes of CP; instead the levels of
MACS were distributed across diagnoses in about the same way
as the GMFCS (Gorter et al. 2004).
Interestingly, several parents mentioned the importance of
highlighting the children’s ability to use their hands. We also
believe that MACS will enhance the communication among
professionals and families in the same way as the GMFCS, i.e. to
determine the child’s needs, make management decisions, and
compare and generalize results of intervention (Palisano et al.
1997). Our intention is that this first report on MACS will be fol-
lowed by a series of studies designed to deepen the knowledge
of the construct of MACS as well as the knowledge on hand
function in children with CP.
DOI: 10.1017/S0012162206001162
Accepted for publication 30th January 2006.
The data in this paper won the Gayle G Arnold award for best
scientific paper at the 2005 AACPDM Annual Meeting.
Acknowledgements
We acknowledge the parents and therapists without whose
contribution this study would not have been accomplished. We also
thank those parents who participated in the validating process, and
Christinne Imms and the Australian group of therapists for data
collection of the English version. Financial support was granted
from the Sven Jerring Fond, Josef och Linnea Karlssons Memorial
Foundation, and Stockholm Habilitation Service’s research unit.
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