2011 Developing and Validating The Communication Function Classification System For Individuals With Cerebral Palsy PDF

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Dev Med Child Neurol. 2011 August ; 53(8): 704–710. doi:10.1111/j.1469-8749.2011.03996.x.
Developing and validating the Communication Function

Classification System for individuals with cerebral palsy
MARY JO COOLEY HIDECKER1, NIGEL PANETH2, PETER L ROSENBAUM3, RAYMOND D
KENT4, JANET LILLIE5, JOHN B EULENBERG6, KEN CHESTER JR6, BRENDA JOHNSON7,
LAUREN MICHALSEN8, MORGAN EVATT1, and KARA TAYLOR1
1Department of Speech–Language Pathology, University of Central Arkansas, Conway, AR, USA.
2Department of Epidemiology, Michigan State University, East Lansing, MI, USA.

3CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON,
Canada.
4Waisman Center, University of Wisconsin, Madison, WI, USA.
5Department of Communication, Michigan State University, East Lansing, MI, USA.

6Communicative Sciences & Disorders, Michigan State University, East Lansing, MI, USA.
7Speech House, Seattle, WA, USA.
8Department of Speech–Language Pathology, Rush University, Chicago, IL, USA.
Abstract
Aim—The purpose of this study was to create and validate a Communication Function
Classification System (CFCS) for children with cerebral palsy (CP) that can be used by a wide
variety of individuals who are interested in CP. This paper reports the content validity, interrater
reliability, and test–retest reliability of the CFCS for children with CP.
Method—An 11-member development team created comprehensive descriptions of the CFCS
levels, and four nominal groups comprising 27 participants critiqued these levels. Within a Delphi
survey, 112 participants commented on the clarity and usefulness of the CFCS. Interrater
reliability was completed by 61 professionals and 68 parents/relatives who classified 69 children
with CP aged 2 to 18 years. Test–retest reliability was completed by 48 professionals who allowed
at least 2 weeks between classifications. The participants who assessed the CFCS were all relevant
stakeholders: adults with CP, parents of children with CP, educators, occupational therapists,
physical therapists, physicians, and speech–language pathologists.
Results—The interrater reliability of the CFCS was 0.66 between two professionals and 0.49
between a parent and a professional. Professional interrater reliability improved to 0.77 for
classification of children older than 4 years. The test–retest reliability was 0.82.
Interpretation—The CFCS demonstrates content validity and shows very good test–retest
reliability, good professional interrater reliability, and moderate parent–professional interrater
© Mac Keith Press 2011

Correspondence to Dr Mary Jo Cooley Hidecker at Department of Speech–Language Pathology, University of Central Arkansas, Box
4985, Conway, AR 72035–0001, USA. mjchidecker@uca.edu.
ONLINE MATERIAL/SUPPORTING INFORMATION Additional material and supporting information may be found in the
online version of this article. Please note: Wiley–Blackwell is not responsible for the content or functionality of any supporting
information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author of the
article.
HIDECKER et al. Page 2
reliability. Combining the CFCS with the Gross Motor Function Classification System and the
Manual Ability Classification System contributes to a functional performance view of daily life
for individuals with CP, in accordance with the World Health Organization’s International
Classification of Functioning, Disability and Health.
Individuals with cerebral palsy (CP) have sensorimotor and developmental issues that affect
their daily lives by restricting their mobility, manipulation of objects, and/or
communication.1 Within the framework of the World Health Organization’s International
Classification of Functioning, Disability and Health (ICF),2,3 the Gross Motor Function
Classification System (GMFCS)4 and the Manual Ability Classification System (MACS) for
children with CP5 make it possible to classify mobility and handling objects respectively, at
the ICF activity/participation level.6 However, no analogous classification of functional
communication has been available for use in CP practice and research. The lack of a
communication classification tool that is quick, reliable, valid, and easy to use limits the
comparison of descriptive CP epidemiology studies as well as the interpretation and
generalizability of CP treatment studies.
Communication disorders can be described from several perspectives: body structure and
function level, activity level, and participation level, as well as environmental and personal
levels.2,3,7–13 Estimates of communication disorders in CP have varied from 31%14 to
88%.15 This wide range is partly a result of the lack of a consensus definition of
communication disorders within CP research and practice. A recent study from a Norwegian
CP registry reported that 51% of children with CP had speech problems as classified by
ratings of ‘slightly indistinct’, ‘obviously indistinct’, ‘severely indistinct’, or ‘no speech’,
including 19% who had ‘no speech’.16 This population-based estimate reporting indistinct or
no speech may underestimate CP communication disorders as it may not capture other types
of communication problems resulting from hearing or language impairments. However,
reporting speech, language, and hearing difficulties simply suggests the range of associated
impairments in CP, not the more pertinent daily-life issues of how well a child with CP
communicates with family, friends, acquaintances, and strangers.13
The purpose of this study was to create and validate a communication function classification
system (CFCS) for children with CP, for use by a wide variety of individuals interested in
CP. This required a shift from the traditional focus on body structure and function (i.e.
assessing components of speech, language, and hearing problems), to a focus on activity/
participation, specifically the way in which to classify a person’s communication capacity
within real-life situations.
METHOD
The development and validation of the CFCS involved four phases that were
methodologically similar to the development of the GMFCS and the MACS.6 In the first
phase, the CFCS was drafted by a development team. The second and third phases focused
on revision and validation and included a series of four nominal group studies and two
Delphi survey consensus rounds. The fourth phase measured interrater reliability among
professionals and parents, and test–retest reliability. Ethical approval of this research was
granted by the institutional review board at Michigan State University. Institutional partners
in the reliability phase either accepted the institutional review board approval from
Michigan State University or sought and received their own institutional review board
approval.
Phase 1: Initial development

Participants—The 11 participants in this phase were from eight groups of individuals who
had experience with CP and communication: one adult with CP, one parent of a child with
CP, one educator, one neurologist, two occupational therapists, two paediatricians, one
physical therapist, and three speech–language pathologists/researchers (note: one participant
was an educator who has CP so she was counted in both groups).
Procedures—The participants discussed and created the first draft of the CFCS, the
development of which was based on reviews of the literature on functional
communication7,8,10,11,17–21 and the participants’ experiences of communication in real-life
situations. Participants shared their ideas through a series of five conference calls and
subsequent e-mails. The number of conference-call participants varied from two to three per
call to accommodate participants’ schedules. Discussions and suggested revisions were then
shared by e-mails and subsequent phone calls. Each element of the CFCS was evaluated for
usefulness and clarity.
Results—The initial draft of the CFCS included the following variables that the
development team viewed as important components of functional communication: (1)
sender skills: conveying a message to a communication partner, which may (but not
necessarily) include intelligible speech and expressive language skills; (2) receiver skills:
understanding a message sent by a communication partner, which may (but not necessarily)
include functional hearing and receptive language skills; (3) pace of communication:
conversational turn taking that occurs at an expected speed without long pauses between
sending and receiving; (4) degree of familiarity with the communication partners: how well
one knows the partner can influence the success of the communicative event as
conversations are constructed between two or more people; (5) age-appropriateness:
communication skills are expected to be commensurate with the child’s developmental
level; and (6) use of augmentative and alternative communication (AAC): including
communication methods such as manual signs, pictures, communication boards,
communication books, and talking devices (sometimes called voice output communication
aids or speech-generating devices).
The initial development process concluded when the participants were satisfied with the
CFCS draft. The draft, which included the six components discussed by the phase 1
development team, was then evaluated by the nominal groups in the next phase.
Phase 2: Nominal groups

Participants—The nominal group included 27 participants from Canada and the USA. See
Table I for participant characteristics.
Procedures—The nominal group process fosters discussions among individuals in order

to create a consensus opinion.22,23 Four nominal group rounds were held to achieve content
validity. Participants were placed into nominal groups by schedule preferences. When
scheduling permitted, at least one member from each of the eight stakeholder groups was
included in each nominal group. Two weeks before the nominal group process began,
participants were sent the open-ended questions and the latest version of the CFCS
(questions are available upon request from the corresponding author).
Each group was given the opportunity to discuss the CFCS during a 4-hour time block. An
experienced group facilitator (PLR for one and JL for the other three nominal groups) was
present to ask questions, move between topics, restate participants’ thoughts, suggestions,
and ideas, provide structure during the meeting, and ask the group to vote on different
suggestions to determine consensus. Individuals’ first names were used to encourage

equality among members, despite differing experiences and educational backgrounds. The
first author (MJCH) was also present during the nominal group process to answer questions
about the CFCS, but she refrained from adding comments or suggestions.
Results—This nominal group process included progressive feedback whereby each group
suggested changes and raised issues, building upon the previous group’s revisions. The
changes and issues that received a majority vote from that nominal group were incorporated
into the next revision. This serial consideration continued until the last nominal group
mostly suggested wording changes and a consensus emerged about the concepts.
Discussion from the early nominal group clarified the point that the CFCS levels
encompassed the range of communication effectiveness and that the CFCS wording was
understandable to stakeholders’ differing perspectives. The creation of a CFCS level
identification chart was suggested and, subsequently an algorithm was incorporated into the
CFCS.
Phase 3: Delphi surveys

Participants—The Delphi phase consisted of 112 participants who were recruited
internationally. All participants from round 1 were invited to participate in round 2, and 69
of the original 112 completed Round 2. See Table I for participant characteristics.
Procedures—Delphi surveys provide a structured method for stakeholders to provide

anonymous feedback.22,23 The purpose of the surveys was to reach a large number of
individuals with expertise in CP in order to evaluate the clarity, conciseness, and usefulness
of the CFCS draft. Delphi surveys were conducted in rounds until a preset 80% target
agreement was reached on all closed-ended questions. The round 1 Delphi survey, with 36
questions similar to those used in the nominal groups, was completed in a Web- or paper-
based format (questions are listed in Table SI, supporting information published online). A
second Delphi survey round was held for the one question that did not reach the targeted
80% agreement. Open-ended responses were analysed for themes and possible changes for
the CFCS.
Results—All but one closed-ended question received greater than 80% agreement in round
1. That closed-ended question (on being able to differentiate between the CFCS levels)
received more than 80% agreement in round 2 after wording changes were made to the draft.
Responses to some of the open-ended questions had the common themes of describing
communication pace, making global judgements of communication performance, and
including all communication methods such as AAC. Delphi survey respondents felt that the
CFCS might be useful in classifying functional communication, providing a common

terminology, assisting with clinical decision making, being used with the GMFCS and
MACS to provide a functional profile of an individual’s performance, and recognizing all
the communication methods including AAC. A ‘frequently asked questions’ section was
created from these themes and is available on the CFCS website (http://cfcs.us).
Phase 4: Interrater and test–retest reliability

Participants—Participants in the reliability phase comprised 61 professionals and 68
family members (primarily parents) from the USA and Canada who classified 69 children
with CP (age range 2y–18y; median age 5y 0mo; mean age 6y 6mo, SD 3y 6mo). The
children’s GMFCS and MACS classifications varied (see Table I for participant
characteristics; see Table II for characteristics unique to the children).The test–retest
reliability was completed by 48 of the professionals.
Procedures—To calculate the interrater reliability, at least two professionals and one
parent were asked to classify the communication performance of a child with CP. As stated
in the CFCS instructions, the classification should be made by someone who is familiar with
the child’s everyday communication. Interrater reliability (weighted kappa) was calculated
between each pair of professionals and between each parent/relative and each professional
involved with the same child. Professionals classified a child’s communication performance
twice with at least a 2-week interval between classifications. In 25% of cases, the child was
not present at the reclassification, and the professional used case notes and/or his previous
interactions with the child to make the second classification. In addition, the raters were
asked to provide information about their educational level, CP experiences, and team role
(i.e. parent or professional), as well as the child’s characteristics including birth date,
comorbidities, communication methods, and GMFCS and MACS levels.
Results—Table III presents the five CFCS levels as well as a comparison with the five
levels of the GMFCS and MACS. The CFCS, with instructions, definitions, and additional
details, can be downloaded at www.cfcs.us for clinical and research use. The weighted
kappa interrater reliability among professionals for the 68 children classified was 0.66 (95%
confidence interval [CI] 0.55–0.78). Table IV shows the distribution of the resulting 73
CFCS classification comparisons. The interrater reliability may be related to the child’s age
at the time of the CFCS classification: on the sample of children who were aged 5 years and
older, weighted kappa improved to 0.77 (95% CI 0.66–0.89). The professionals’ familiarity
with the child varied from only a first visit to the provision of ongoing services. However,
sub-analyses by the professionals’ familiarity or by the settings of clinic, school, or home
did not change CFCS agreement.
A subset of 48 professionals reclassified the children’s communication performance at least

2 weeks after the initial classification, after noting that the child had not had any intervening
health change. The weighted kappa test–retest reliability was 0.82 (95% CI 0.74–0.90).
Table IV shows the distribution of the resulting 89 CFCS classification test–retest
comparisons.
A parent and a professional classified the communication performance of the same child.
The weighted kappa interrater reliability between professionals and parents for 69 children
was 0.49 (95% CI 0.40–0.59). Table IV shows the distribution of the resulting 138 CFCS
classification comparisons. Professionals tended to classify the child’s communication as
less effective than the parent’s classification. When the parent–professional interrater
reliability was calculated on the sample of children aged 5 years and older, the weighted
kappa decreased to 0.42 (95% CI 0.29–0.55).
DISCUSSION
The CFCS was empirically derived from the communication disorders literature and expert
experience to classify patterns of an individual’s communication performance in one of five
levels of everyday communication effectiveness with a partner (Table III). Communication
occurs when conversation partners establish a shared understanding.24,25 This shared
understanding (i.e. communication) results from an interaction among components of ICF
activity, participation, and body structure and function (e.g. speech, language, and hearing
skills) with contextual factors (e.g. setting, conversational partner skills, AAC methods, and
cultural backgrounds).2,3,12
Systematically including multiple stakeholders in the development and validation of the

CFCS provided different viewpoints that led to important insights and helped to create a
classification that is more likely to be stakeholder-friendly for professionals and lay people.
It provides a global judgement of functional communication performance at the ICF activity/

participation level, regardless of the specific body structure and functions relating to a
communication disorder or another specific diagnosis. The CFCS classification considers all
communication methods including AAC use.
The test–retest reliability of the CFCS was very good, and professional interrater reliability
was good.26 The interrater reliability between parents and professionals was moderate, with
parents tending to classify their children’s communication as being more effective than
professionals perceived it to be. Parents are likely to see the children in more environments
and with more communication partners, but at the same time parents may underestimate the
difficulty that unfamiliar communication partners may have in communicating with the
children. Research is needed to explore and understand the differences underlying parents’
and professionals’ classifications.
Communication is quite different from walking and object manipulation, which depend
largely or entirely on the capacity of the individual doing those activities, although
environmental factors do influence whether and how these activities are performed.
Communication is the exchange of information between people, and the responsibility for
communication, therefore, is typically shared between conversational partners. The CFCS
classification requires a rater to know how the individual with CP communicates with both
unfamiliar and familiar communication partners in different environments in order to
establish shared understandings.
A distinction between classification and assessment is critical in order to understand the

CFCS and similar instruments. The GMFCS, MACS, and CFCS are not assessments or tests,
although they may be complementary to detailed assessments.6 Classification systems are
designed to recognize and distinguish varied ‘levels’ of functional patterns. In contrast,
assessments or tests are systematic, usually standardized, methods of collecting or
measuring aspects of the person. As with the GMFCS and the MACS, the CFCS does not
explain the reasons why a person’s performance falls within a particular classification level.
Building on the conceptual foundation of the ICF, functional patterns may be due to
differing aspects of the person and contextual factors including speech intelligibility, hearing
sensitivity, language skills, AAC competencies, and familiarity of conversational partners
and their communication skills. The CFCS classification task of making a global judgement
of effective communication may be novel to some individuals, especially those who are not
speech–language pathologists or otherwise trained in communication. Familiarity and
practice with the CFCS concepts may be needed to improve interrater reliability.
Possible age effects were considered throughout the development of the CFCS. As
mobility,27 hand function, and communication performances typically improve as children
develop, the effect of age on performance is not surprising. For example, in one study using
the GMFCS, younger children were better described by three levels that differentiated into
five more consistent GMFCS levels as the child grew older.25 The improvement in interrater
reliability for the CFCS in children older than 4 years may also suggest an age effect. To
address the effect of age, the GMFCS uses age bands to describe mobility performance at
different ages. The MACS is not recommended for use with children under 4 years of age,
whereas the CFCS has been used with children as young as 2 years old. An age-cohort study
about the stability of the CFCS in CP is needed and could provide an insight into CFCS
levels and age effects across the lifespan of an individual.
Several research projects are currently using the CFCS, including some that are validating
the CFCS in languages other than English. These CFCS translations will be posted on the
CFCS website (www.cfcs.us) as they become available. Similar CFCS validation and
reliability studies are needed to determine the applicability to other populations, including
individuals with autism, Down syndrome, hearing loss, and those who have suffered a
stroke. If the CFCS classifies communication performance at an activity/participation level
then, in theory, the CFCS should be applicable to communication regardless of the

underlying body structure and function issues. What would vary by diagnostic group would
be any potential prognostic implications associated with a particular classification.
The development of the CFCS addressed some of the limitations of classification by (1)
proposing a valid and reliable tool for clinical and research applications that seek to classify
communication at an ICF activity/participation level;2,3 (2) including previously
underrepresented groups such as adults with CP and parents of children with CP in its
development, and (3) providing a common language when talking with an individual with
CP, family members, and other professionals. Combining the CFCS with GMFCS and
MACS levels contributes to a functional performance view of daily life for individuals with
CP.
What this paper adds

• Describes the development and validation of a communication classification
system for children with CP (CFCS), including content validity and reliability.
• The CFCS categorizes communication at the activity/participation level of the
ICF.
• The system was developed as an analogue of the GMFCS and the MACS,
potentially to create functional profiles of people with CP.
Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
Acknowledgments
This research was supported in part by a National Institutes of Health postdoctoral fellowship (NIDCD F32
DC008265–02) to the first author, as well as grants from the Cerebral Palsy International Research Foundation and
The Hearst Foundation to the first three authors.
We thank those who chose to participate in the research anonymously. We also thank all individuals and institutions
that contributed to this study. (A list of all those who contributed to this study can be found online).
ABBREVIATIONS
AAC Augmentative and alternative communication

CFCS Communication Function Classification System
MACS Manual Ability Classification System
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NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Table I
Participant Characteristics of the participants in the development of the Communication Function Classification System
Nominal Delphi Delphi Reliability: professionals and

group, survey – survey – parents/relatives, n=129 (%)
n=27 (%) Round 1, Round 2,
n=112 (%) n=69 (%)
HIDECKER et al.
Stakeholder groups
Adults with CP 3 (11) 16 (14) 12 (17) 1 (1)
Educators 4 (15) 8 (7) 5 (7) 13 (11)
Neurologists 1 (4) 5 (5) 5 (7) 3 (2)
Occupational therapists 2 (7) 8 (7) 3 (4) 10 (8)
Parents or relatives of children 4 (15) 7 (6) 4 (6) 68 (55)
with CP
Paediatricians 3 (11) 13 (12) 8 (12) 4 (3)
Physical therapists 3 (11) 11 (10) 5 (7) 13 (11)
Speech-Language 7 (26) 42 (38) 28 (41) 16 (13)
pathologists/researchers
Others 4 (15) 24 (21) 13 (19) 4 (3)
Professionals, Parents/relatives, Children
n=61 (%) n=68 (%) with CP,
n=69
(%)
Sex
Female 19 (70) 90 (80) 56 (81) 50 (82) 59 (87) 26 (38)
Male 8 (30) 22 (20) 11 (16) 11 (18) 9 (13) 43 (62)
Missing 0 (0) 0 (0) 2 (3) 0 (0) 0 (0) 0 (0)
CP experience
Fewer than 5y 2 (7) 6 (5) 1 (1) 7 (11) 37 (54) –
5–10y 3 (11) 20 (18) 7 (10) 20 (33) 19 (28) –
Greater than 10y 22 (82) 86 (77) 61 (89) 34 (56) 11 (16) –
Missing 0 (0) 0 (0) 0 (0) 0 (0) 1 (2) –
Racial/ethnic
White 26 (96) 107 (97) 66 (97) 59 (97) 56 (82) 59 (86)
Black 0 (0) 2 (2) 1 (2) 1 (2) 5 (7) 9 (13)
American Indian/Alaska native 0 (0) 1 (1) 1 (2) 1 (2) 3 (4) 4 (6)
Page 10
Nominal Delphi Delphi Reliability: professionals and

group, survey – survey – parents/relatives, n=129 (%)
n=27 (%) Round 1, Round 2,
n=112 (%) n=69 (%)
Asian/Pacific Islander 1 (4) 0 (0) 0 (0) 2 (3) 5(7) 8 (12)

Hispanic 0 (0) 1 (1) 1 (2) 0 (0) 10 (15) 14 (20)
Missing 0 (0) 2 (2) 1 (2) 0 (0) 0 (0) 0 (0)
HIDECKER et al.
Education
Grade school 0 (0) 0 (0) – 0 (0) 1 (2) –
Some high school 0 (0) 2 (2) – 0 (0) 3 (4) –
High school graduate 2 (7) 2 (2) – 0 (0) 11 (16) –
Some college 0 (0) 4 (4) – 2 (3) 17 (25) –
College graduate 7 (26) 9 (8) – 14 (23) 22 (32) –
Graduate school or advanced 18 (67) 95 (85) – 45 (74) 14 (21) –
degree
Some participants chose multiple categories. n is based on the number of respondents, so the individual categories may not sum to n participants or sum to 100%.
Page 11
Table II
Characteristics of children with cerebral palsy who participated in the reliability phases of development of the
CFCS (also see Table I)
Characteristics Number (%), n=69 (%)
GMFCS level
I 7 (10)
II 18 (26)
III 7 (10)
IV 13 (19)
V 23 (33)
Missing 1 (1)
MACS level
I 8 (12)
II 24 (35)
III 9 (13)
IV 13 (19)
V 12 (17)
Missing 3 (4)
Comorbidities
Apraxia of speech 18 (26)
Autism/pervasive developmental disorder 3 (4)
Cognitive impairment, mild 16 (23)
Cognitive impairment, severe 23 (33)
Developmental delay 58 (84)
Dual sensory impairment 3 (4)
Dysarthria 24 (35)
Emotional-behavioural disorder 3 (4)
Hearing impairment, temporary 3 (4)
Hearing impairment, permanent 5 (7)
Language disorders 32 (46)
Seizure disorders 37 (54)
Visual impairment not corrected by glasses 31 (45)
Communication methods used

Speech 41 (59)
Sounds 49 (71)
Eye gaze, facial expressions, gesturing, and/or pointing 51 (74)
Manual sign 20 (29)
Communication boards, books, and/or pictures 19 (28)
VOCAs or SGDs 16 (23)
Some participants chose multiple categories. The number is based on the number of respondents so the individual categories may not sum to n
participants or sum to 100%. GMFCS, Gross Motor Function Classification System; MACS, Manual Ability Classification System; CFCS,
Communication Function Classification System; VOCA, voice output communication aid; SGD, speech-generating device.
Table III
The five levels of gross motor function (GMFCS) manual ability, (MACS), and communication function
(CFCS) classification systems
Classification systems
Levels GMFCS MACS CFCS
I Walks without limitations Handles objects easily and Sends and receives with familiar
successfully and unfamiliar partners
effectively and efficiently
II Walks with limitations Handles most objects but with Sends and receives with familiar
somewhat reduced quality and unfamiliar partners but may
and/or speed of achievement need extra time
III Walks using a hand-held Handles objects with difficulty; Sends and receives with familiar
mobility device needs help to prepare and/or partners effectively, but not with
modify activities unfamiliar partners
IV Self-mobility with limitations; Handles a limited selection of Inconsistently sends and/or
may use powered mobility easily managed objects in receives even with familiar
adapted situations partners
V Transported in a manual Does not handle objects and has Seldom effectively sends and
wheelchair severely limited ability to receives, even with familiar
perform even simple actions partners
Table IV
Reliability of the Communication Function Classification System (CFCS)
Professional interrater reliability (weighted kappa)=0.66 (95% CI 0.55–0.78)
Professional 1 CFCS classification, n

Professional 2 CFCS I II III IV V Total
HIDECKER et al.
classification, n
I 5 2 3 1 11
II 2 3 5 2 12
III 7 2 9
IV 6 17 4 27
V 1 13 14
Total 7 5 21 23 17 73
Test–retest reliability by professionals (weighted kappa)=0.82 (95% CI 0.74–0.90)

Time 2 CFCS classification, n
Time 1 CFCS I II III IV V Total
classification, n
I 11 11
II 2 7 9
III 1 3 11 15
IV 1 2 7 21 31
V 3 20 23
Total 15 12 18 24 20 89
Parent–professional interrater reliability (weighted kappa)=0.49 (95% CI 0.40–0.59)
Professional CFCS classification, n
Parent CFCS I II III IV V Total
classification, n
I 10 4 3 2 19
II 7 9 9 12 1 38
III 6 9 7 6 28
IV 1 4 24 11 40
V 2 11 13
Total 17 20 25 47 29 138
Note: Absolute agreement counts are highlighted. CI, confidence interval.

Page 14

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Dev Med Child Neurol. 2011 August ; 53(8): 704–710. doi:10.1111/j.1469-8749.2011.03996.x.

Developing and validating the Communication Function

2Department of Epidemiology, Michigan State University, East Lansing, MI, USA.

5Department of Communication, Michigan State University, East Lansing, MI, USA.

© Mac Keith Press 2011

Classification of Functioning, Disability and Health.

Phase 1: Initial development

Phase 2: Nominal groups

Table I for participant characteristics.

Procedures—The nominal group process fosters discussions among individuals in order

suggestions to determine consensus. Individuals’ first names were used to encourage

Phase 3: Delphi surveys

Procedures—Delphi surveys provide a structured method for stakeholders to provide

CFCS might be useful in classifying functional communication, providing a common

Phase 4: Interrater and test–retest reliability

A subset of 48 professionals reclassified the children’s communication performance at least

Systematically including multiple stakeholders in the development and validation of the

It provides a global judgement of functional communication performance at the ICF activity/

communication methods including AAC use.

establish shared understandings.

A distinction between classification and assessment is critical in order to understand the

then, in theory, the CFCS should be applicable to communication regardless of the

What this paper adds

AAC Augmentative and alternative communication

4. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of

5. Eliasson A, Krumlinde-Sundholm L, Rösblad B, et al. The Manual Ability Classification System

Communication, Inc; Monterey, CA: 2003.

Nominal Delphi Delphi Reliability: professionals and

Nominal Delphi Delphi Reliability: professionals and

Asian/Pacific Islander 1 (4) 0 (0) 0 (0) 2 (3) 5(7) 8 (12)

CFCS (also see Table I)

Characteristics Number (%), n=69 (%)

Communication methods used

(CFCS) classification systems

Levels GMFCS MACS CFCS

Professional interrater reliability (weighted kappa)=0.66 (95% CI 0.55–0.78)

Professional 1 CFCS classification, n

Test–retest reliability by professionals (weighted kappa)=0.82 (95% CI 0.74–0.90)

Parent–professional interrater reliability (weighted kappa)=0.49 (95% CI 0.40–0.59)

Professional CFCS classification, n

Note: Absolute agreement counts are highlighted. CI, confidence interval.

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