Information for users

The Mini-Manual Ability Classification System (Mini-MACS) is a classification system

that describes how children with cerebral palsy (CP) aged 1–4 years use their hands
when handling objects in daily activities. Ability is ranked on five levels based on the
children’s self-initiated ability and their need for assistance or adaptation when
handling objects. This brochure also describes differences between adjacent levels to
make it easier to determine the most appropriate level. Mini-MACS is a functional
description that can be used as a complement to the supposed diagnose of CP and its
subtypes.

The description concern how the children handle objects relevant for age. The objects
referred to are those commonly found in the children’s environment which they use
when performing tasks, such as playing, drawing, eating, or dressing. How children
handle toys often gives a good idea of their manual ability. Obviously, a 12-month-old
child does not handle the same toys and other objects as a 4-year-old. A child’s
motivation and cognitive ability also influence the ability to handle objects and,
consequently, the Mini-MACS level.

When assessing a child's Mini-MACS level, choose the level that best describes the
child's usual performance in the daily environment. To better understand what a child
usually does, and how he or she performs this activity, it is necessary to ask someone Mini-Manual Ability Classification System
who knows the child well. The questions should be phrased to obtain a description of
the type of objects the child handles, in what situations, and how. Mini-MACS levels for children with cerebral palsy
reflect what the child usually does, not his or her best performance as demonstrated in
a specific test situation.
1 - 4 years of age

Mini-MACS assesses the child's general ability to handle everyday objects, not the
function of each hand separately. Mini-MACS does not intend to explain the underlying The Manual Ability Classification System (MACS) described how children
reasons for impaired manual capacity. aged 4–18 years with CP use their hands when handling objects in daily
activities. Mini-MACS is an adaptation of MACS for children aged 1–4
The Mini-MACS system spans the entire spectrum of functional limitation found among years.
children with CP and covers all CP sub diagnoses. Level I includes children with minor
limitations, if any, while children with severe disabilities are usually classified on level  Mini-MACS classifies children’s ability to handle objects that are relevant for
V. Certain CP subtypes can be found at all levels, e.g., bilateral CP, while unilateral CP their age and development as well as their need for support and assistance
usually occurs at levels I–III. Mini-MACS does not include children without physical in such situations.
disabilities; if it did, they would be classified as level “0”. However, no such level exists!
 Mini-MACS describes how children usually use their hands to handle
objects, such as toys, in various settings. In other words, it describes what
Since Mini-MACS consists of only five levels, each level includes children with they ordinarily do, rather than what is known to be their best capacity.
relatively varied function. Consequently, Mini-MACS is a classification system,
probably not sensitive to changes and should therefore not be used to evaluate
 Mini-MACS classifies the child’s overall ability to handle objects, not the
development or interventions. Mini-MACS can be used to describe and differentiate
ability of each hand separately.
into five levels functional aspects on how a suspected CP diagnosis affects children’s
manual ability.
 To find out how a child handles various objects in everyday life, it is
necessary to ask someone who knows the child well. Such knowledge
The five-level Mini-MACS scale is ordinal, which means that the differences between cannot be obtained through specific testing. The questions should be
levels are not necessarily equal, nor are children with CP equally distributed across the phrased to obtain a description of the type of objects the child handles daily,
five levels. in what situations, and how.
©Ann-Christin Eliasson, Lena Krumlinde-Sundholm, 2013
Contributers: Ann-Marie Öhrwall, Ulla Wahlström, Åsa Persson-Annersten, E-mail: [Link]@[Link]
[Link]
 What do you need to know to use Mini-MACS?
Distinctions between Levels I and II
Mini-MACS users need to find out what objects the child usually handles and how
they handle them: with ease or difficulty, quickly or slowly, with precision or randomly? Children in Level I may have slightly more difficulty handling items that
For example, you can ask about and/or observe how the child uses his or her hands require good fine motor skills compared to children without disabilities of
when playing and during meals, or when participating in usual activities of daily living. the same age.
Children in Level II handle essentially the same objects as children in
Level I, but they may encounter problems performing tasks and/or take
Ask questions about the child’s self-initiated ability and how much adult help and
longer to perform them, so they often ask for help. Functional differences
support the child needs to handle everyday objects, e.g. toys.
between hands may cause performance to be less effective. They may
need more guidance and practice to learn how to handle objects
Below is a description of the five Mini-MACS levels of children’s self-initiated ability compared with children in Level I.
and their need for assistance or adaptation when handling objects.

I. Handles objects easily and successfully. The child may

have a slight limitation in performing actions that require precision Distinctions between Levels II and III
and coordination between the hands but they can still perform them.
Children in Level II can handle most objects, though they may take longer
The child may need somewhat more adult assistance when handling and do so with somewhat less quality, and they may need a lot of
objects compared to other children of the same age. guidance and practice to learn how to handle objects.
II. Handles most objects, but with somewhat reduced Level III children manage to use easily handled objects but often need
quality and/or speed of achievement. Some actions can help placing objects in an easy position in front of them. They perform
actions with few subcomponents. Performance is slow.
only be performed and accomplished with some difficulty and after
practice. The child may try an alternative approach, such as using
only one hand. The child need adult assistance to handle objects
more frequently compared to children at the same age. Distinctions between Levels III and IV
III. Handles objects with difficulty. Performance is slow, with Children in Level III manage to use easily handled objects independently
limited variation and quality. Easily managed objects are handled for short periods. They perform actions with few subcomponents, and
independently for short periods. The child often needs adult help and the actions take a long time to perform.
support to handle objects. At best, children in Level IV can perform simple actions such as
grasping and releasing easily handled objects that are offered in an
IV. Handles a limited selection of easily managed objects adapted position. They need constant help.
in simple actions. The actions are performed slowly, with
exertion and/or random precision. The child needs constant adult
help and support to handle objects. Distinctions between Levels IV and V
V. Does not handle objects and has severely limited Children in Level IV perform individual actions with a very limited
selection of objects and need constant help.
ability to perform even simple actions. At best, the child At best, children in Level V perform simple movements in special
can push, touch, press, or hold on to a few items, in constant situations. For example, they can press a simple button or hold single,
interaction with an adult. simple objects.