The Double ABCx Theory

of Family Stress and

Adaptation
Suzanne Kang & Johanna Sotelo
GNRS 508A
Research and Theory in Advanced
Practice Nursing
Marissa Brash DrPH, MPH, CPH
Jane Pfeiffer, PhD, RN
 Double ABCX Theory & History
Hamilton I. McCubbin served as Professor &
Head of the Department of Family Social Science
Joan A. Patterson served as a Research Associate of
the Department of Family Social Science

Double ABCX, conceptualized by McCubbin and Patterson & is an expansion of

Reuben Lorenzo Hills Family Stress Theory (ABCX Theory).

Hill was an American Sociologist and Educator.

Studied families responses to WWII (war itself, familial separation, reunion)
3 components in ABCX: 1) Stressor 2) Familys response 3) Familys
perception of the stressor
Interactions of these 3 factors indicated the crisis-proneness of the family.
Based on traditional nuclear family.
(McCubbin, & Patterson, 1983; LoBiondo-Wood, 2008)
 Double ABCX Theory
Used to study family stressors such as
chronic illness in children, cancer, and
elder care.

Outcome in Double ABCX Model is

adaptation.

Throughout history, the Double ABCX

Model has adapted to reflect the ever
changing dynamics of a family.

Most recent model emphasizes

(LoBiondo-Wood, 2008)
 Geri LoBiondo-Wood
Geri LoBiondo-Wood, PhD, RN, FAAN, was the
nurse researcher who introduced McCubbin and
Pattersons Double ABCX Model into nursing
research.

She conducted several studies using their model

as a guiding framework.

Studied the impact of child liver transplant on the

family (1992, 2000, 2004)

Fellow of the American Academy of Nursing

(LoBiondo-Wood, 2008; LoBiondo-Wood, Williams, L., & McGhee,
(AAN). 2004)
 Double ABCX Family Stress and
Adaptation Key Terms
Stressor (A): Life event or transition impacting
the family unit that produces (or has the potential
to) change in the family social system
Existing Resources (B): familys use of
community as well as intrafamilial resources.
Can be education, SES, religion
Perception of Stressor (C): meaning family
assigns to crisis event and total circumstances
leading to crisis.
Crisis (X): Demand for change
Pile Up (aA factor): managing changes, strains,
and stressors over time.
Existing and New Resources (bB): Existing,
new, and expanded resources allow the family to
adapt and meet demands and needs. Result
from aA factor
Perception of the Stressor (cC): family view,
definition, and significance given to the stressor
and resulting hardship, pile-up stressors, and
meaning of family attaches to total situation.
Coping: active process utilizing the new and
existing resources that help strengthen the family
unit.
Adaptation (xX): the outcome, family
accommodated, compromised, and given
(LoBiondo-Wood, 2008)
Image of theory
 Metaparadigm
Person: Family is seen as the person

Environment: The setting in which the family

lives, their resources, and stressors they face

Health: Stressors and Crisis surrounding the

impaired health of a family member, keeping
them for well being

Nursing: Holistic centered care where

teaching and support is provided to the entire
family unit
(Theory of family stress and adaptation, n.d.)
 Contributions
Applicable to pediatric and adult patients

Ezer, et al. (2006) conducted studies on family adaptation

when incorporating wives of prostate cancer patients.
Nursing interventions increased wives manageability,
meaningfulness, and comprehensibility of life events

Most relevant in organ transplantation, cancer,

psychiatric illnesses and dementia

(Ezer, 2006; LoBiondo-Wood, 2008)

 Strengths and Weaknesses of Theory
Strengths: Weaknesses:

Focuses on the family as a
whole and allows for
measurement of multiple family
qualities.
Model adapted to reflect how
the view of family has changed
and expanded
All concepts defined and widely
tested for their psychometric
properties.
Large number of concepts. With the numerous extensions,
the concepts may be difficult to distinguish well from one
another.
I.e. family resource overlap with family problem
solving and coping
Individual resources are interchangeable with family
resources, but they are conceptually distant when
defined in the model.
An event specific stressor may not be an adequate
conceptualization because it can be too narrowly focused.
Should be viewed broadly as a crisis event

Family constellation needs to be better (LoBiondo-Wood,

defined. 2008)
 Theory Based Care: Case Study #1
Situation: 25 y/o female in MVA two weeks ago. Came in with 9/10 pain to upper left abdomen for
two days. Pain radiated to her back. Her right arm was fractured and casted, her left arm had
extreme tingling and immobile. She was unable to move both. Her husband passed in the car
accident and she was left with two children.

Assessment: A/Ox4, awake, alert and oriented, skin presented with scabs from abrasion, multiple
bruises to body, skin was dry and slightly cyanotic, s1/s2 auscultated, tachycardic, radial and pedal
pulses +2 equal bilaterally, no murmurs, pain to abdomen was in left upper quadrant and radiated to
back, but also in midepigastric area, pain 6/10 on morning assessment. Signs of dyspnea and slight
crackling auscultated in lungs, N/V alleviated by zofran. Lab results demonstrated elevated levels of
amylase and lipase.

Vital Signs: Temp: 100.1F, HR: 110 bpm, RR: 26 breaths/min, SpO2: 98%, B/P: 115/90, Pain: 6/0-
10,

Diagnosis: Acute pancreatitis, fracture to R wrist, hand and phalanges and brachial plexus injury to
left shoulder.
 Theory Based Care: Case Study #1
Nursing Diagnosis: Grieving
r/t death of spouse in MVA aeb
verbalization of despair, altered
sleep patterns, crying with
family members, and hopes of
discharge before funeral.
Goal: Patient will identify ways
to support family members, and
articulate methods of support
she requires from family and
friends before end of shift.
Interventions:
listen to family members story.
Validate the clients feelings of
grief and feeling hurt, stressful,
anxious, and other symptoms of
grieving.
Be present and attentive, use
active empathetic listening.
Encourage prayer and a quiet
healing environment
(Ackley, Ladwig, & Makic, 2017, p.420-425)
 Theory based Care (Cont.)
Evaluation: patient was successful in meeting goal. She verbalized the
continued support being given to her by her family and her husbands
family with care of her children as she recovers in the hospital. She
understands life will not be the same without him, however she has a
desire to make it through her grieving to be strong for her two boys.

The model would be successful for this patient because the stress of
loss affects not only the patient, but everyone in her family.
Adaptation will come via support as she recovers with their help.
She appears to be a resilient woman, who even though has
experienced a life altering event, is determined to continue through
life with a positive outlook.
 Theory Based Care: Case Study #2
Situation: 75 y.o. complaining of left facial droop with numbness and left upper and lower extremity
weakness for the past 3 days. Numbness and tingling is associated with the extremity weakness. Patient
has difficulty swallowing, denies speech or vision difficulty. Patient recently had a kyphoplasty, 5 days ago in
L5 compression fracture.

Assessment: A&Ox4. Speech clear, slight facial droop on left side. Numbness on left lower arm, leg, and
face. Light touch present. Left upper and lower extremities weaker than right upper and lower extremities.
Able to swallow by self. Advised to monitor when taking medication. Needs applesauce to assist with
swallowing. Limited range of motion with left arm due to extremity weakness. Some weakness occasionally
with gait (left side) while walking with 40 feet with walker. Admits she is not having a great down, visibly
shows frustration with daily activities. Husband present; visibly frustrated as well. Husband wants wife to be
independent; wife, in pain wants assistance and wants to go at her own pace.

Vital Signs: Temp: 97.5*F, BP: 187/75, HR: 84 bpm, RR: 18/min, O2 sat: 98% RA, Pain 8/10, numeric scale
(back; L5 where kyphoplasty was 5 days ago)

Diagnosis: Right, Subacute Ischemic Stroke

 Theory Based Care: Case Study #2
Nursing Diagnosis: Interrupted family
process r/t situational debilitation from
recent stroke and broken back AEB
patients frustration over inability to get
up and walk by herself, dependence on
husband to help reach her telebox, and
husbands frustration over wifes
impulsiveness.
Goal: Have husband participate in the
development of the plan of care to the
best of his ability.
Interventions:
Spend time with family members
and allow them to verbalize their
feelings and perceptions of the
health care experience.
Encourage husband to say words
of encouragement to wife when
she is frustrated.
Educate patient of the importance
of independence for her recovery.
(Ackley, Ladwig, & Makic, 2017)
 Case Study #2 (Cont.)
Evaluation: Patient goal met. Husband was able to participate in patient goal. He
verbalized understanding that although he may want his wife to be completely
independent, it will be harder for her due to her recent back surgery and overall
fatigue from activity.

Understands he will need to be patient with her and was overheard telling his
wife he loved her and was proud of her.

Patient noticeably less frustrated as she was able to verbalize to husband

she needed to rest before getting up to sit in the chair by herself.

Patient understands it is important for her to be independent and expressed

hope in being discharged to rehabilitation.
 Usefulness and Evaluation
Usefulness
The theory can be used in families
with children who suffer chronic
illnesses.
Holistic nursing approach involves
entire family, physical and mental
health.
Easy applicability to all populations
and family dynamics.
Barriers to the adaptation of theory
Lack of resources
Lack of cooperation from family
members to participate, or share
resources
Healthcare provider time restraints
Resistance to adaptation
Effects of griefs on family members
 References
Ackley, B.J., Ladwig, G.B., & Makic, M.B.F. (2017). Nursing Diagnosis Handbook (11th ed.). St Louis, MO: Elsevier.
Ezer, H., Ricard, N., Bouchard, L., Souhami, L., Saad, F., Aprikian, A., & Taguchi, Y. (2006). Adaptation of wives to
prostate cancer following diagnosis and 3 months after treatment: a test of family adaptation theory. International
Journal Of Nursing Studies, 43(7), 827-838.
LoBiondo-Wood, G. (2008). Theory of family stress and adaptation. In Smith, M. J., & Liehr, P. R. (Eds.), Middle range
theory for nursing, (2ed ed.) (pp. 225-241). Retrieved from http://0-ebookcentral.proquest.com.patris.apu.edu

LoBiondo-Wood, G., Williams, L., & McGhee, C. (2004). Liver transplantation in children: Maternal and family stress,
coping, and adaptation. Journal for Specialists in Pediatric Nursing, 9(2): 59-66.

McCubbin, H. I., & Patterson, J. M. (1983). The family stress process: The double ABCX model of adjustment and
adaptation. Marriage & Family Review, 6(1-2), 7-37.

Theory of family stress and adaptation. (n.d.). Retrieved from http://theorywikigroup5.weebly.com/theory-critique.html