Initiating a task at an unspecified time draws on executive function. For some people, that demand is difficult, no matter how much they want to do it. Doing it once a day may be difficult. Doing it consistently twice a day adds another layer of demand.

What looks simple from the outside may require considerably more cognitive effort for this person.

Those two explanations lead to completely different problem-solving.

One assumes the problem is willingness or motivation.

The other asks whether there is a mismatch between what the plan demands and how this specific person processes, organizes, remembers, or initiates action. By mismatch, I mean a gap between what the interaction or plan demands and what works for the person trying to carry it out.

And there are plenty of other possibilities. The point is not to replace one assumption with another.

What do we actually know?

We know the exercises were not done. We do not yet know why.

Observable behavior is information, not explanation.

This is where the HEArT framework is useful. It gives us five stages of the interaction to evaluate before assigning meaning to the behavior.

When a patient does something we do not understand, we naturally try to explain it. The danger comes when the explanation arrives before the investigation.

What happens when the behavior we are interpreting is being shaped by something we cannot see? Neurodivergence is one useful example of why this matters.

I am not a specialist in neurodivergence. My focus here is narrower: what neurodivergence can show us about mismatches between the demands of a clinical interaction and how a person processes or acts on them.

Neurodiversity describes variation in how human brains process information and experience the world. It describes variation across people and populations.

Neurodivergent describes an individual whose neurological development or functioning differs from dominant norms. Autism, ADHD, dyslexia, developmental coordination disorder, dyscalculia, and Tourette syndrome are commonly included, although there is no universally agreed list.

It’s important to know that the term itself is not a diagnosis. And you will not reliably know who in front of you is neurodivergent.

This is not an argument that the patient who did not complete the home program has ADHD.

Neurodivergence makes the problem especially clear because the same observable behavior can plausibly be interpreted in very different ways.

Is it long processing time or… disengagement?

Is limited eye contact simply more comfortable for them, or are they completely uninterested?

Is difficulty initiating what was agreed on an executive-function roadblock or… noncompliance?

Every one of these is a possible interpretation of observable behavior.

Research describing autistic adults' healthcare experiences gives us one well-studied example. Fast-paced communication, broad open-ended questions, unexpected changes, and sensory overload can all make communication more difficult in the moment.

How many of those demands are built into an ordinary day in your clinic?

Wait without knowing how long. 

Move into another room and wait again.

Recall a timeline accurately.

Interpret unfamiliar medical language.

Tolerate touch from someone you have just met.

Remember several instructions, then go home and initiate those instructions hours later.

For some patients, those demands add cognitive, sensory, or executive-function load to a system already managing pain, fear, fatigue, uncertainty, and other pressures.

Neurodivergence gives us an especially clear example of why these conditions deserve clinical attention.

That does not mean creating a completely different clinical pathway for every person who enters the building.

It means noticing what the interaction is asking of the person in front of you.

• The four-item home program looked simple.

• The open-ended question looked like the same one you use at every appointment.

• The change in plans looked minor for your team.

Those descriptions tell us what the interaction looked like from the clinician's side.

They do not tell us what it required from the patient.

Neurodivergence is one possible source of mismatch. So are pain, fear, literacy, culture, previous healthcare experiences, competing demands, misunderstanding, environmental pressure, and genuine disagreement.

The HEArT framework does not require the clinician to know the source of the friction before responding.

It asks something more fundamental:

What is creating the friction in this interaction?

Neurodivergence does not require a separate HEArT pathway.

It demonstrates why evaluating the interaction matters in the first place.