Special thanks to Mara Goverman for facilitating this interview. You can hear more from Ms. Goverman on our podcast, available wherever you get your podcasts.

CCPR: Let’s start with the big picture. How does a child’s capacity to plan ahead and think about the future develop from early childhood through young adulthood?
Dr. Feder: Development unfolds in stages, and planning ahead is one of the last pieces of executive function to form. In early years, we focus on regulation, connection, and meaningful back-and-forth interaction with caregivers. Symbolic thinking, the ability to mentally represent something that isn’t happening right now, emerges around ages 2–4, often in play, such as bedtime scenarios with dolls that work through something that happens in the future. From there, logical reasoning, multicausal thinking, and eventually genuine reflective capacity build across childhood and the teen years. (Editor’s note: See “Developmental Stages and Clinical Implications in Adolescent Psychiatry” table for the full arc.) Those later stages extend well into middle adulthood. One key factor is myelination of white matter tracts supplying the prefrontal cortex. That process continues into the mid-30s (Mousley A et al, Nat Commun 2025;16(1):10055). So, the ability to set aside distractions, inhibit impulses, and plan ahead is limited in teenagers—not for lack of trying, but for lack of hardware.

CCPR: What does incomplete prefrontal development look like in clinical practice with teens?
Dr. Feder: We see substance use, unprotected sex, and other decisions with no consideration of what comes next. Subtler examples include kids with the drive to make the world better, but with impulsive actions—like throwing out every plastic item in the home, including their siblings’ toys, to protect the family from plastics. But, by the late teens, many kids focus better and regulate reliably; some of them no longer need medications they once depended on. A tween who couldn’t conceptualize consequences may, at age 14, strategize how to convince their parents they need to stay out late, rather than merely sneaking out and getting grounded. That’s planning ahead, although in the service of thwarting curfew. By 17 or 18, we want them managing their own medications, schedules, and other tasks. It’s not perfect at 18, but the trajectory matters.

“As patients become more regulated, connected, and reflective, I look for opportunities to taper or discontinue medications. That moment when someone who needed pharmacological support is now stable enough to explore doing with less is something to actively watch for and celebrate.” - Joshua D. Feder, MD

CCPR: How do social determinants (eg, poverty, community trauma, chronic stress) affect this developmental trajectory?
Dr. Feder: Significantly, sometimes permanently. Think about a family in a flood-prone, low-income neighborhood that loses their home with little warning. That experience can prematurely undermine normal teen confidence in their own invulnerability and their confidence in the adults around them. Chronic stressors (ongoing poverty, food insecurity, community violence) keep the nervous system in a state of sustained vigilance. There’s evidence of intergenerational epigenetic impact, where methylation patterns in families from chronically stressed communities keep baseline catecholamine tone elevated. This results in increased arousal; tendency to go into fight, flight, or freeze; and reduced capacity for productive problem-solving (Shkarina L et al, Front Psychiatry 2026;17:1764368). You also tend to see more rule-based, authoritarian parenting in these settings. That’s often adaptive: If a police encounter could be dangerous, you need your kid to know exactly how to behave. But it dampens the exploratory, autonomous problem-solving that builds reflective capacity over time. Kids in these situations are at higher risk for traumatization and, in some cases, radicalization (Bertrand C et al, J Fam Psychol 2023;37(3):388–397). Understanding a family’s social context isn’t background noise; it’s central clinical data that guides your care.

CCPR: As reflective capacity develops, how does that change therapy?
Dr. Feder: It’s continuing metamorphosis—a new kid at every stage. Younger children don’t have symbolic thinking, and you’re doing parent coaching to improve responsive caregiving. Once symbolic thinking arrives, you can work with it: Anthropomorphizing OCD into a monster that makes a child wash their hands excessively gives them something to push back against. When logical reasoning is possible, you can leverage that insight: “When I skip my homework, I’m more depressed.” This causal thinking makes them partners in treatment rather than recipients. And as reflective capacity matures, motivational interviewing becomes increasingly effective. Adolescents can weigh the pros and cons of their choices, try something different, and report back on how it went. (Editor’s note: For more on depression and anxiety in this age group, see CCPR Oct/Nov/Dec 2025.)

Sources: Greenspan SI and Shanker SG. The First Idea. Cambridge, MA: Da Capo Press; 2004; Meeks JE and Bernet W. The Fragile Alliance, 5th ed. Malabar, FL: Krieger Publishing Company; 2001; Siegel DJ. Brainstorm. New York, NY: TarcherPerigee; 2015. Developmental age ranges are approximate and vary by individual and social context.

CCPR: How do you help the teen who is so dysregulated, by trauma or biology, that they can’t access higher-level thinking and problem-solving?
Dr. Feder: Identify an adult (a parent, grandparent, teacher, counselor, or social worker) whom the teen trusts. Help that person to stay steady when the teen is upset by encouraging communication as well as maintaining good limits. I explain to parents that this gives the teen a place to decompress before returning to everyday life. For example, for a teen who experienced repeated sexual abuse, I helped his grandparents respond less reactively, framing his dysregulation as biologically based. I taught them calming strategies, such as deep breathing, and to remember that outbursts pass. As they became calmer, his episodes decreased in frequency and severity (Murray DW et al, Prev Sci 2023;24(6):1187–1197). Staying calm doesn’t mean perfectly calm; that can aggravate some situations. It may mean matching about 80% of their emotional intensity—enough that they feel understood and can settle enough to think, but not so much that you’re both dysregulated. “That sounds awful. You don’t want to feel like a pariah with your friends” is more useful than “I understand your concern.”

CCPR: How do you approach supporting a teen, or their parents, in the kind of collaborative problem-solving you’re describing?
Dr. Feder: Listen carefully, paraphrase back what you’re hearing, and wonder aloud rather than telling them what to do. Use reflective language, comparing past to present, noticing internal states, staying curious, and holding multiple perspectives. We can offer this to parents during interactions and teach them how to do the same with kids. Brainstorm together, including outlandish options, and think about which ones to try. Preserve their agency and give them practice at problem-solving. If you solve their problems every time, you take away learning opportunities. I do this in parallel with parents: I wonder with them, perhaps offering what other families have tried, and letting them arrive at their own approach. That builds their competence and confidence as well as their child’s competence and confidence. For example, consider a lonely non-athletic child who loved baseball. The parent opened up the conversation: “You love baseball. What might you do for the team besides playing?” The child was unsure, and the parent said: “That’s okay—take a minute. Teams need helpers. What else could someone do?” After a pause, the child said, “Maybe… manager?”

CCPR: What about the emergence of more serious conditions during adolescence and young adulthood, like schizophrenia, bipolar disorder (BD), or substance use disorders (SUDs)? How does the developmental lens apply there?
Dr. Feder: Schizophrenia is best understood as a neurodevelopmental disorder that “flowers” in the late teens and early 20s. But there are almost always earlier signs: subtle cognitive differences, social aloofness, unusual thinking. It’s worth noting that psychotic-like experiences are more common in youth than many clinicians realize. About 9% of children and adolescents report such experiences, with rates around 17% in the 9–12 age group and about 7.5% in ages 13–18 (Kelleher I et al, Psychol Med 2012;42(9):1857–1863; Healy C et al, Psychol Med 2019;49(10):1589–1599). The teens who preserve reflective capacity—who can think, “Maybe people are watching me; maybe they’re not”—are prognostically in better shape. Preserved reflective capacity is a clinical sign worth tracking. BD also impairs reflective thinking, especially during florid mania. With both conditions, insight is often the first casualty. Patients who don’t feel ill don’t stay on medication, and it can require several hospitalizations before they solidify the reflective capacity to understand that they need the medication to remain stable.

CCPR: How are SUDs different from schizophrenia or BD?
Dr. Feder: Addiction is, intrinsically, an override of reflective capacity. The decision point can be the first use. Even a single encounter with nicotine can trigger addiction. Developmentally geared educational and harm reduction conversations need to happen before exposure. Once addiction takes hold, motivational interviewing is probably our most effective tool, perhaps because it slows things down enough for reflection to happen (Schwenker R et al, Cochrane Database Syst Rev 2023;12(12):CD008063).

CCPR: How do you assess where a particular teen is developmentally, and how do you talk with them and their families about it?
Dr. Feder: Try to understand how this specific kid puts ideas together and plans ahead, as well as what they don’t consider. A useful framework is the capacity to consent or assent to health care decisions: Do they understand what’s being proposed? Can they weigh it? Can they communicate a preference (Katz AL et al, Pediatrics 2016;138(2):e20161485)? That’s a practical scaffold for developmental assessment, especially as a teenager approaches 18. Describe the pattern directly but without judgment: “Johnny tends to see something he wants and goes for it. That’s real initiative. Let’s think together about where that serves him well and where it sometimes gets in the way.” Then you move into the same collaborative problem-solving posture. You’re not prescribing a solution; you’re thinking aloud with them about what they notice and what they want to try. Cultural context matters too. Some families prioritize individual achievement and autonomy; others organize around the collective well-being of the family. These are different framings of developmental success.

CCPR: Any final thoughts or a take-home message for clinicians working with children and adolescents as they develop?
Dr. Feder: Follow the developmental trajectory and give teens the opportunity to practice agency because practice is how this capacity grows. And for prescribers specifically: As patients become more regulated, more connected, and more reflective, I look for opportunities to taper or discontinue medications (Walter HJ et al, J Am Acad Child Adolesc Psychiatry 2020;59(10):1107–1124). That moment when someone who needed pharmacologic support earlier is now stable enough to explore doing with less is something to actively watch for and celebrate. It’s one of the clearest signs of true maturation.

CCPR: Thank you for your time, Dr. Feder.