DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Correspondence of classifications between parents of children with

cerebral palsy aged 2 to 6 years and therapists using the Gross Motor
Function Classification System
ASHLYN T JEWELL | ASHLEY I STOKES | DOREEN J BARTLETT

School of Physical Therapy, Faculty of Health Science, The University of Western Ontario, London, Ontario, Canada.
Correspondence to Professor Doreen J Bartlett at The School of Physical Therapy, Room 1588, Elborn College, The University of Western Ontario, London, Ontario N6G 1H1, Canada.
E-mail djbartle@uwo.ca

PUBLICATION DATA
Accepted for publication 16th October 2010.
Published online 17th December 2010.
AIM The aim of this study was to determine the agreement and reliability of parent report using a
lay version of the Gross Motor Function Classification System (GMFCS) among children with cere-
bral palsy in the two youngest age bands.
METHOD Data were obtained from the Canadian section of the Movement and Participation in Life
Activities of Young Children study database. One hundred and thirty-two parents of two groups of
children participated: children aged 2 to 4 years (35 males, 26 females; mean age 3y 2mo; SD
5mo) and children aged 4 to 6 years (39 males, 32 females; mean age 4y 11mo; SD 6mo) at the
final data collection point. Therapists classified motor function using the GMFCS and parents used
the GMFCS Family Report Questionnaire, with parents and therapists being masked to the others’
responses. Agreement between respondents was determined using precise agreement and
Cohen’s unweighted kappa statistic. Reliability between respondents was determined using the
intraclass correlation coefficient (ICC).
RESULTS Overall, precise agreement was 77%, chance-corrected agreement was j=0.70 (95%
confidence interval [CI] 0.61–0.79), and reliability was ICC=0.95 (95% CI 0.93–0.96).
INTERPRETATION These values indicate substantial agreement and reliability between parents of
children aged 2 to 6 years and therapists. Some parents had a tendency to rate their children as
more functionally limited than did therapists, leading us to question whose the true criterion
standard’ rating should be.

Cerebral palsy (CP) refers to a group of permanent, non-pro-
gressive disorders of development of motor function affecting
movement and posture in addition to causing activity limita-
tion.1 The Gross Motor Function Classification System
(GMFCS) was first described by Palisano et al.2 to classify the
motor function of children with CP. An expanded version that
includes older age bands and revision of some details was sub-
sequently published.3 Differences in motor function are
reflected in the five classification levels of the GMFCS. Chil-
dren classified in level I can walk without restrictions but they
lack more advanced gross motor abilities. Those in level V are
limited in self-mobility, even with the use of assistive technol-
ogy.2 Children are assigned a level based on their functional
capabilities and typical performance according to specific age
bands (<2y, 2–4y, 4–6y, 6–12y, 12–18y).
As cited in previous research, content validity2–5 of the
GMFCS has been established for ages 2 to 18 years. Face5
and construct6 validity have been established for ages 2 to
12 years. Agreement between raters2,7,8 and stability over
time3,9,10 have been demonstrated on many occasions. A
convenience sample from five children’s treatment centers in
Ontario demonstrated moderate support for interrater agree-
ment (j=0.75) in all GMFCS levels for children aged 2 to
12 years.2 The validity of the GMFCS for children aged 12 to
18 years3 has been established, but reliability has not yet been
established for this oldest age band.
The GMFCS is widely used among healthcare professionals
to determine clinical decisions involving future rehabilitation,
equipment needs, and functional mobility goals. Typically, the
parent or guardian has more insight into their child’s overall
abilities because they view the child in various environments
over a longer period of time.11 Accordingly, it is important to
determine the level of agreement between healthcare profes-
sionals and parents when classifying a child with CP using ver-
sions of the GMFCS.
Reliability of family report using the GMFCS has been
established for children aged between 6 and 12 years (intra-
class correlation coefficient [ICC]=0.94).12 Interobserver
agreement in a diverse sample of children aged 4 to 18 years
has also been determined.8 However, results have not been

334 DOI: 10.1111/j.1469-8749.2010.03853.x ª The Authors. Journal compilation ª Mac Keith Press 2010
reported for the 2- to 4-year and 4- to 6-year age bands What this paper adds
separately. The purpose of this project was to examine the pre- • The Family Report Questionnaire provides a reliable means of classifying chil-
cise agreement, chance-corrected agreement, and reliability of dren with CP between the ages of 2 to 4 and 4 to 6 years.
parent report using the GMFCS in children with CP aged 2 • Assuming therapists' ratings are the criterion standard underestimates the
to 4 years and 4 to 6 years, as well as for the group as a whole. value of parent report.
• Agreement about a child's GMFM level is essential in providing collaborative
family-centered care.
METHOD
The following research was part of a 1-year prospective obser- shown in Table I. Children were categorized into two age
vational study that incorporated comparisons of the GMFCS groups based upon age at the final time point: 2 to 4 years (35
ratings between two observers (parent ⁄ guardian and health- males, 26 females; mean age 3y 2mo; SD 5mo) and 4 to
care professionals, who were primarily physical therapist asses- 6 years (39 males, 32 females; mean age 4y 11mo; SD 6mo).
sors) at the final data collection point. Data were obtained
from the Canadian section of the Movement and Participation Assessors and data collection procedures
in Life Activities of Young Children (Move & PLAY) study Parents or guardians of the children and the therapist assessors
database. This study was coordinated through the CanChild classified each child’s GMFCS level independently. Therapists
Centre for Childhood Disability Research at McMaster Uni- classified the GMFCS at the end of the 45-minute assessment
versity, Ontario, Canada and included the following sites: St session at the final data collection point. Parents had previ-
John’s, Halifax, Peterborough, Toronto, Winnipeg, Regina, ously completed the parent self-report booklet in which they
Vancouver, and Victoria. The ethics committees at the Uni- identified the child’s GMFCS level using the appropriate age
versity of Western Ontario, and McMaster University (as well version of the GMFCS Family Report Questionnaire,8,14
as six of the participating sites) approved the project before which is available at the CanChild website (http://www.
data collection. canchild.ca). Further details of the full data collection proce-
dures are contained in an earlier study.13 Demographic char-
Participants acteristics of parents and families are shown in Table II. The
The sample included 132 children with CP living in eight geo- participating parents were primarily mothers (87%) and had
graphical locations across Canada. The population eligible for an educational level of college diploma or higher (72%). Ther-
inclusion in this study was families of children with a diagnosis
of CP as determined by an attending physician or a delay in
gross motor development and ⁄ or impairments in muscle tone, Table II: Demographic and clinical characteristics of parents ⁄ carer raters
equilibrium reactions, balance, and active range of motion
Age group, n (%)
during movement as determined by the physical therapist
assessor. Exclusion criteria were children younger than 2–4y 4–6y
18 months or older than 5 years as well as children who had a Relationship to child Mother 56 (91) 59 (83)
diagnosis other than CP. Details of the convenience sampling Father 1 (2) 8 (11)
procedure are contained in an earlier paper.13 Participants Adoptive mother – 3 (4)
Adoptive father 1 (2)
were assessed at three time periods: the start of the study, Foster mother 2 (3) 1 (2)
6 months later, and 1 year from the start of the study. Before Grandmother 1 (2) –
data collection, parents provided signed informed consent for Highest level of Less than high school 2 (3) 2 (3)
education for parents High school 15 (25) 18 (25)
both participation and publication of study results. Community college 26 (43) 26 (37)
The children were between the ages of 18 and 60 months at diploma
the beginning of the study, and were aged between 2 years Bachelor’s degree 11 (18) 16 (23)
Master’s degree 7 (11) 8 (11)
6 months and 6 years at the final data collection point. The Doctoral degree – 1 (1)
children’s GMFCS levels and distribution of involvement are

Table I: Distribution of involvement of child participants by Gross Motor Function Classification System (GMFCS) level

GMFCS level (therapist ratings), n (%)

I II III IV V Totala

Distribution of involvement Monoplegia 3 (8) 1 (7) 0 (0) 0 (0) 0 (0) 4 (3)

Hemiplegia 28 (74) 1 (7) 2 (10) 0 (0) 0 (0) 31 (24)
Diplegia 6 (16) 6 (43) 7 (33) 3 (12) 0 (0) 22 (17)
Triplegia 0 (0) 2 (14) 3 (14) 0 (0) 0 (0) 5 (4)
Quadriplegia 1 (3) 4 (29) 9 (43) 22 (88) 33 (100) 69 (53)
Total 38 (100) 14 (100) 21 (100) 25 (100) 33 (100) 131 (100)

a
One participant missing.

Parent Report Reliability of the GMFCS Ashlyn T Jewell et al. 335

apist assessors determined the child’s GMFCS level at the j=0.70 (95% CI 0.61–0.79). Chance-corrected agreement was
beginning and end of the study, with the latter rating used for more favorable in levels I and V and less favorable in levels II
this study. to IV in the younger age group. The older age group demon-
strated more favorable agreement in levels IV and V and less
Statistical analysis favorable agreement in levels I to III.
The GMFCS uses an ordinal scale that has five levels.2 The ICC indicating reliability between families and thera-
Descriptive statistics were used to indicate the number of chil- pist assessors for children aged 2 to 4 and 4 to 6 years was
dren in each GMFCS level as rated by the families and thera- 0.93 (95% CI 0.88–0.95) and 0.96 (95% CI 0.94–0.98) respec-
pist assessors. Ordinal data were analysed using percentage tively. The overall ICC between families and therapists was
agreement and Cohen’s unweighted kappa statistic (j) to 0.95 (95% CI 0.93–0.96). ICCs between parent and therapist
examine the agreement between parent and therapist assessor assessors exceeded 0.90, representing excellent reliability.15
in terms of both precise and chance-corrected agreement. The The most frequent number of disagreements in the 2- to
ICC (2,1; Portney and Watkins15) was also calculated for com- 4-year age band occurred in levels III and IV. Therapists were
parison with existing reliability literature. Standards for more likely to rate children at a higher functional ability than
strength of agreement as proposed by Landis and Koch16 were family report; however, the opposite results were also seen. In
used to interpret the data, such that values of j between 0.41 12 out of 16 cases of disagreement (75%), parents classified
and 0.60, 0.61 and 0.80, and 0.81 and 1.0 indicate moderate, their children as less functional. In the 4- to 6-year age band,
substantial, and excellent agreement respectively. disagreements most frequently occurred between levels I and
II. In 14 of 15 cases of disagreement (93%), children were
RESULTS classified as less functional by their families. No disagreement
All children who participated in this study were classified using occurred by more than one level in this age band.
the GMFCS by both the therapist and the parent assessors
(n=132). Tables III and IV present the results of agreement DISCUSSION
between parent and therapist assessors for children in age The results indicate substantial agreement and reliability
bands 2 to 4 years and 4 to 6 years respectively. The precise between parent and therapist assessors for children with CP
agreement between parents and therapist assessors was calcu- aged 2 to 4 years and 4 to 6 years who are classified using the
lated as 74% in the younger age group, 79% in the older age GMFCS. This study suggests that family ratings on the
group, and 77% overall. Results revealed substantial levels of GMFCS using the Family Report Questionnaire8,14 corre-
chance-corrected agreement between parent and therapist spond well with therapists’ classifications across the spectrum
assessors for both the 2- to 4-year age group (j=0.66, 95% of functional ability levels. Strong agreement between ratings
confidence interval [CI] 0.53–0.79) and the 4- to 6-year age made by families and healthcare professionals has been con-
group (j=0.73, 95% CI 0.60–0.85); for overall agreement, firmed in previous research with children of similar and differ-
ent ages.8,14 The measures of chance-corrected agreement for
Table III: Gross Motor Function Classification System (GMFCS) levels as parent–therapist reliability (j=0.66 and 0.73) in this study are
rated by family and therapists for children aged 2 to 4 years slightly lower than the chance-corrected agreement between
therapists (j=0.75) reported in the initial GMFCS study for
GMFCS classification by therapist assessors children with CP aged 2 to 12 years.2 Our values are also
Level I Level II Level III Level IV Level V Total
lower than those in other studies of parent report agreement
and reliability;8,12,14 however, our sample included children at
GMFCS Level I 14 – – – – 14 younger ages. As expected, measures of agreement and reliabil-
classification Level II – 4 1 1 – 6
by parents ⁄ Level III – 3 7 1 – 11
ity obtained between therapist assessors and families were con-
families Level IV – 1 5 5 1 12 sistently higher in the older age group than the younger one.
Level V – – – 3 15 18 The difference between the age bands, as well as our values
Total 14 8 13 10 16 61
compared with other studies, can be attributed to the increased
stability in functional ability of older children with CP. This
concept has been described in previous studies identifying a
Table IV: Gross Motor Function Classification System (GMFCS) levels as greater tendency for children less than 6 years of age to be
rated by family and therapists for children aged 4 to 6 years reclassified to a less functional level on the GMFCS scale.8,9
The pattern of disagreement found in this study has been
GMFCS classification by therapist assessors reported in previous research12 suggesting that families allo-
Level I Level II Level III Level IV Level V Total cate children to levels of lower functional ability (e.g. level II)
whereas assessors tend to assign children at a higher level
GMFCS Level I 18 – – – – 18
classification Level II 7 5 – – – 12
of ability (e.g. level I). Assigned GMFCS levels may be
by parents ⁄ Level III – 1 5 – – 6 dependent upon the environment in which the child is
families Level IV – – 3 12 1 16 observed. Researchers tend to minimize limiting variables of
Level V – – – 3 16 19
Total 25 6 8 15 17 71
the environment to ensure validity of the assessment findings.
Although this provides sound methodological reasoning for

336 Developmental Medicine & Child Neurology 2011, 53: 334–337

measuring capacity, it also affects the children’s ratings as their
capabilities (rather than usual performance) are assessed within
a structured environment. Therefore, family report of a child’s
functional abilities may provide greater insight to the service
provider.
The primary limitation of this study was the relatively small
sample size of participants in each of the two age ranges. We
only had 61 and 71 participants in the 2- to 4-year and 4- to
6-year age bands respectively. Future work is necessary to
ascertain the stability of these findings among other groups of
parents and service providers.
The results of this study raise the question, ‘Who is the cri-
terion standard for classifying children with CP: parent or
therapist?’ The development of the GMFCS has relied on
ratings by healthcare professionals however, assuming health-
care professionals’ ratings are the criterion standard would
underestimate the value of parent report. A child’s movement
abilities are perceived and experienced differently by families
and healthcare professionals owing to the effect of the envi-
ronment in which the child is being observed.17 Healthcare
professionals usually assess children in standardized environ-
ments, such as clinical or school settings. Structured and regi-
mented curricula are implemented in these environments to
promote children’s best functional abilities. That said, families
spend more time and interact with children in a variety of set-
tings and, therefore, can identify a child’s strength and limita-
tions, which leads to a true determination of their functional
abilities.
To determine whether families are more or less reliable
than healthcare professionals in reporting classification levels
for children with CP is not possible; the disagreement may
simply be a result of perspective. Perhaps, as stated by Morris
et al., the criterion standard lies with the perspective that the
researcher is interested in: the professional or the family
rating.12
Trusting partnerships between families and healthcare pro-
fessionals need to be established in clinical practice to provide
effective collaborative family-centered care. Healthcare profes-
sionals must recognize parents as experts in their children’s
needs and abilities across a broader range of settings. How-
ever, families will always rely upon the professional opinion of
doctors and therapists. We believe it is useful for both health-
care professionals and parents to make independent classifica-
tions. In the case of agreements (which occur in most
instances), no further action need be taken. In the case of
discordance, we believe it is useful to discuss and come to a
consensus on a classification as a basis for making subsequent
clinical decisions.
CONCLUSION
The substantial agreement demonstrated in this study suggests
that parent reports of the GMFCS using the GMFCS Family
Report Questionnaire provide a reliable method for classifying
children with CP between 2 to 4 years and 4 to 6 years of age
in most instances. However, it seems prudent to gather data
from both perspectives and reach a consensus in the case of
disagreements as a basis for subsequent collaborations to opti-
mize outcomes for children in the context of their prognoses.
ACKNOWLEDGEMENTS
This work was completed by the first two authors as part of the
requirements of the Master of Physical Therapy degree at the Univer-
sity of Western Ontario, under the supervision of the last author. We
acknowledge the Canadian Institute of Health Research (MOP-
81107) and the US Department of Education, National Institute of
Disability and Rehabilitation Research (H133G060254) for funding
this work. We especially thank Barbara Stoskopf, Project Coordinator
for the Move & PLAY study, for facilitating access to the data, and
Lisa Avery for assisting with refinements to the statistical analyses.

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Parent Report Reliability of the GMFCS Ashlyn T Jewell et al. 337