It’s Not resistance. It’s a Mismatch.

A patient leaves your office with a home program. Four items, twice a day, nothing complicated. Three weeks later they have not done it once.

The automatic assumption is: motivation. The patient does not care enough, or the exercises got left behind against everything else in their life. It’s a reasonable guess, and often wrong in a specific and useful way.

Here is another look at this interaction.

The patient fully intends to do the program. Initiating a task at an unspecified time draws on executive function. For some people, that demand is hard to meet reliably, every time, no matter how much they want to. And certainly not twice a day.

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

It is about how their brain organizes action, every day, in every part of their life, not just this one.

Those two explanations lead to completely different problem-solving. One assumes the problem is willingness and internal motivation. The other asks whether there is a mismatch between what the plan demands and how this specific person processes, organizes, and initiates action.

The point is not to replace one assumption with another. It is to recognize when you are making an assumption at all.

Evaluating the interaction means asking which explanation you are actually looking at before you decide.

Neurodivergence is not a special protocol. It is one of the clearest examples of something true for every patient you see: observable behavior is information, not explanation.

I am not a specialist in neurodivergence. But I do work across a borad range of the human population, which means I am regularly interacting with people who fit this description, and there are experts who can go far deeper than I can on what neurodivergence looks like in daily life.

What I can offer is narrower and, for clinical purposes, still useful: a look at what this means for the interaction itself.

Neurodiversity describes variation in how brains process information and experience the world. It is not a diagnosis. 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, though no universally agreed list exists and the term itself is not a diagnosis.)

You will not reliably know who in front of you is neurodivergent.

CDC data show more than half of U.S. adults diagnosed with ADHD were diagnosed in adulthood. For some adults, late recognition may follow years in which difficulties with organization, initiation, or attention were interpreted in other ways. A clean prevalence number for neurodivergence as a whole does not exist, because the term spans multiple overlapping conditions with no single diagnostic definition.

I think we know more about this intellectually than our everyday clinical environments reflect in practice.

Consider what a mismatch can look like in the room:

Is it long processing time or… disengagement?

Are they a literal communicator or actually hostile?

Limited eye contact is more comfortable for them, or — they are completely uninterested?

Difficulty initiating what was agreed on is an executive-function roadblock or… noncompliance.

Every one of these is a plausible misreading, and every one of them sends the encounter in the wrong direction.

Reviews of autistic adults' healthcare experiences describe exactly this pattern:

fast-paced communication, broad open-ended questions, unexpected changes, and sensory overload each making communication harder in the moment.

Does your clinic run at a fast pace, rely on broad open-ended questions, change plans unexpectedly, or fill the environment with noise and groups of people? How can you adapt the environment for someone who does not function at their best in it?

And healthcare interactions ask a tremendous amount of the brain.

Wait without knowing how long.

Move into a new room, and again, wait without knowing how long.

Filter background noise, sometimes from groups of people, sometimes from strange medical equipment.

Recall a timeline accurately.

Answer broad questions on demand.

Interpret complex, unfamiliar language.

Tolerate touch from a total stranger.

Make decisions quickly.

Remember several instructions.

Then initiate those instructions hours later, at home.

For many people, these demands are manageable. 

For others, one or several may create significant cognitive load. And it’s not the cognitive load that is inherently bad, it’s just one more pressure loaded into a system that might be reaching critical levels of pressure. 

Neurodivergence gives us an especially clear example of why the demands of the interaction deserve clinical attention.

This starts before you walk into the room. 

A waiting room with fluorescent lights and unpredictable wait times, an exam that starts without warning, a transition between rooms with no explanation, or a sudden substitute clinician are not simply hospitality details for some patients. 

They can shape whether the patient can participate in the encounter at all before you have said a clinical word.

In HEArT, this belongs to Hello: the conditions surrounding the conversation can shape a patient's ability to participate before the clinical work even starts.

The value of neurodivergence here is that it exposes a broader clinical problem: we routinely interpret behavior without first examining what the situation demanded of the person producing it.

The six-item home program looked simple.

The waiting room looked ordinary.

The open-ended question is the same you use at every appointment.

The sudden change in plans was minor for your team.

But 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 does not require a separate HEArT pathway. It demonstrates why evaluating the interaction matters in the first place.

The question worth carrying into every encounter where something reads as resistance is simple:

Are you working with unwillingness? Or are you looking at a mismatch between what this interaction demands and how this person processes information?