Behavior Adherence Model (BAM)

Behavior Integration (S4 Model)

The purpose of OTCC’s Behavior Adherence Model (BAM), or more simply known as the S4 model, is to provide a framework that will help clinicians identify and correct breakdowns in follow-through to improve real-world occupational performance. The S4 Scan is a four-step analysis process (see below) that targets key domains, supported by existing evidence, that commonly contribute to difficulty integrating behaviors into daily life. The S4 model should be considered when the following are present:

  • Intervention isn’t being carried out

  • Progress is limited or inconsistent

  • You’re unsure if the plan will translate to daily life

Below is a brief overview of how the model functions. Refer to the full framework for detailed application and supporting evidence.

1. Stimulus

Prompt to initiate behavior

2. Simple

Relatively low complexity and Cognitive Load

3. System

Embed in a routine or life pattern

4. Significant

Meaningful & relevant

S4 Scan: Behavior Integration Rapid Scan

If intervention adherence barriers are present → run S4 scan.

1. STIMULUS: What triggers the action?

Ask:

  • What cues this behavior to occur?

  • Is the environment supporting or interfering?

🚨 Red Flags:

  • “I forgot”

  • Task is out of sight, out of mind

  • Cluttered or undefined spaces

Act:

  • Add visual/environmental cues (object placement)

  • Use alarms or reminders

  • Create dedicated spaces or zones

  • Reduce competing distractions

2. SIMPLE: Can they realistically do it?

Ask:

  • Is the task too complex, long, or fatiguing?

  • Does it require too many steps or decisions?

🚨 Red Flags:

  • “It’s too much”

  • Partial completion or avoidance

  • Visible overwhelm

Act:

  • Reduce to 1–2 key actions

  • Shorten duration / reps

  • Simplify setup or instructions

  • Introduce adaptive strategies/equipment as needed

3. SYSTEM: Is it built into daily life?

Ask:

  • When exactly does this happen?

  • Is it tied to an existing routine?

🚨 Red Flags:

  • “I’ll do it later”

  • Inconsistent follow-through

  • No defined time or context

Act:

  • Anchor to an existing habit (e.g., after brushing teeth)

  • Schedule at a consistent time/place

  • Align with daily rhythms (morning, meals, bedtime)

4. SIGNIFICANT: Does it matter to them?

Ask:

  • Why does this matter to the client?

  • Does it connect to their goals, roles, or identity?

🚨 Red Flags:

  • “I know I should…”

  • Low engagement or passive agreement

  • Drop-off when it becomes challenging

Act:

  • Link to meaningful occupation

  • Reframe in client-centered language

  • Revisit and align with occupational profile

⚡ Rule of Thumb: If the behavior isn’t happening, one or more of the 4 S’s is misaligned. (adjust the system, not the expectation)

Clinical Integration

Use during:

  • Intervention planning

  • HEP design

  • Reassessment (lack of progress)

  • Discharge planning

Evidence & Resources

OT Alignment: