Development and Validation of the Toileting Function Classification System for Children With Cerebral Palsy Ages 6-18

Abstract

Importance: Children with cerebral palsy (CP) and other neurodevelopmental conditions often face significant toileting challenges because of motor, sensory, cognitive, and behavioral impairments, as well as environmental factors such as limited caregiver awareness. These difficulties affect daily function and participation, yet they are often overlooked when documenting daily challenges in existing functional classification systems or care planning.

Objective: To develop and validate the Toileting Function Classification System (TFCS) for children with cerebral palsy ages 6-18, enabling tailored interventions and resource allocation.

Design: A six-phase approach: initial conceptualization and drafting, preliminary refinement, expert consultation through interviews, stakeholder consensus building through nominal and focus groups, Delphi-based content validation, and reliability assessments similar to those of other functional classification systems.

Setting: Various clinical and research environments involving experienced professionals, caregivers, and children with CP.

Participants: One hundred eighty children with CP, 180 caregivers, and 24 professionals with expertise in CP and toileting.

Outcomes and measures: Reliability (interrater and test-retest consistency) was measured using weighted κ; consensus was evaluated through Delphi surveys.

Results: The Delphi survey achieved over 80% agreement on key TFCS components across two rounds. Reliability values ranged from .61 to 1.00, demonstrating substantial to almost perfect agreement. The system successfully classified toileting functions across five levels, supporting its clinical and research applications.

Conclusions and relevance: The TFCS provides a reliable framework for documenting and addressing toileting challenges in children with CP. Its implementation enhances family-professional communication and guides rehabilitation programs, ultimately improving quality of life. Plain-Language Summary: Toileting is a complex part of daily life that can be especially challenging for many children with disabilities. Difficulties with toileting are often linked to a combination of physical, sensory, and cognitive factors and may be even greater when conditions such as cerebral palsy occur alongside intellectual or developmental disabilities. This study focused on children with cerebral palsy and the development of a new classification system to describe their toileting function in a structured way. This tool can help occupational therapists and families better understand a child's needs and plan appropriate supports, contributing to improved care and quality of life.