When we talk about long-term outcomes after HIE, motor skills often take the spotlight—but what about thinking, learning, and paying attention? Cognitive development, especially executive functioning, deserves just as much, well... attention!
Dr. Melisa Carrasco McCaul from the TREES Lab at the University of Wisconsin agrees. Her team is leading a groundbreaking initiative to better define and support cognition in kids with HIE—starting with the Virtual A² pilot study.
She recently joined Hope for HIE for a live Q&A to discuss this pilot program, how families can get involved, and what the latest research tells us about long-term cognitive outcomes after HIE.
Missed the live Q&A? No worries. Like any good partner, we took notes and are willing to share!
Before we dive into the cognitive impacts of HIE, let's take a step back and talk about what we mean when we say "cognition" and "executive functioning."
Cognition is all about how we think, learn, and understand the world. It includes voluntary and involuntary processes that help us get through daily life—things like understanding information, problem-solving, communicating, language skills, attention, and adapting to our environment. In children with HIE, some brain areas that support these skills—especially the frontal and temporal lobes—can be affected, which is why they often need extra support, particularly in developing executive function.
Executive functioning is a key part of cognition— it's like the brain's management system. Executive functions are practical, down-to-earth skills like planning, emotional regulation, memory, and self-control. These skills allow kids to stay engaged during a lesson, shift between activities, control impulses, and recover when something doesn't go their way.
When HIE affects these areas, it can impact how children learn and interact with the world—but here's the hopeful part: because young brains are still developing and highly adaptable, there's a real opportunity to support and strengthen these skills early on. Just like we've focused on early intervention for motor development, we're learning that the same principles apply to cognitive development. With the right support through play, therapy, and intentional interaction, we can help kids not only be ready for school—but thrive in it and beyond.
We're really just beginning to understand the long-term cognitive impacts of HIE—especially when it comes to executive functioning. Therapeutic hypothermia, or cooling therapy, has only been standard practice in the U.S. and other countries for about 20 years. That means the first generation of kids treated with it is just now reaching their teenage years and early adulthood, making this a brand-new and rapidly evolving area of research.
What we do know is that kids with HIE are incredibly resilient. That resilience helps carry them far—but it doesn't take the place of support. Researchers, including those at the TREES Lab in Wisconsin, are working to better understand what cognitive and executive functioning challenges these kids might face, and—just as importantly—how we can support them in the ways that matter most. There's still a lot to learn, but the goal is clear: to better understand how children with HIE think, adapt, and thrive so we can meet their needs earlier and more effectively.
When it comes to HIE, long-term outcomes—especially around cognition—are a little trickier to define. Everyone knows about motor milestones because they're visible and easy to track: sitting up, crawling, walking. But wouldn't it be amazing to have a poster of cognitive milestones, too? We're not quite there yet.
Cognitive development is harder to measure because it's not as visibly obvious or linear. You can't give a baby a quiz to see how they're doing. It takes time, training, and a lot of nuance to really understand how a child is taking in and responding to the world around them.
But we're getting closer. In the next few years, our hope is to build clearer timelines and tools that help both parents and providers recognize what to look for and when.
Right now, Dr. Carrasco McCaul often tells families to pay attention around 6 to 9 months for early signs—things like vocalizing, responding to social cues, or showing interest in what's happening around them. If a baby is socially engaged, that's a great sign. It usually means they're motivated to learn, communicate, and connect.
That said, we also know that even as early as 6 months, babies with HIE may engage a little differently. They might not explore toys the same way, or they may show curiosity in a more subtle or delayed fashion. Take the puppet test - yes, we said puppets! In this task, a baby watches a puppet perform a repetitive action. Most typically developing babies will eventually get bored and shift their attention elsewhere—that's a sign of cognitive flexibility. But babies with HIE often respond in one of two ways: they might not engage with the puppet much at all, or if they do, they have a hard time looking away. That tells us something about how their attention systems are working—and raises important questions. Are they missing learning opportunities because they're not noticing them? Or are they getting "stuck" because it's harder to shift gears?
Now, the presence of these challenges doesn't equate to incapability —it just means they might need extra support. And that's precisely why this work matters: to understand what these early differences mean and how we can help bridge those gaps and tailor early interventions that support attention, flexibility, and learning right from the start.
Let's be honest—who's truly "typical" anyway? We're all a little neurodiverse in our own ways. But from a research perspective, understanding the range of developmental pathways helps us identify where extra support might be helpful.
One of the most exciting current research areas is figuring out how to better support long-term cognitive development in children with HIE. Historically, there haven't been many targeted interventions—largely because we didn't have enough children to study who had survived HIE and were old enough for this kind of follow-up. But that's changing fast.
A powerful program called the Abecedarian Approach is a major influence on current work. Initially developed in the 1970s to support children at risk due to socioeconomic factors, it later showed great promise when adapted in the 1980s for children with cerebral palsy. The results were remarkable: kids in the program demonstrated significant cognitive gains, thanks to consistent, individualized, play-based interaction with a trained interventionist.
Dr. Melisa Carrasco McCaul and her team recognized the success of the Abecedarian Approach and its potential to meet a critical need in the HIE community— but as promising as the approach is, access has always been a hurdle. It relies on frequent, one-on-one sessions—typically in person—limiting availability, especially for families far from primary research or therapy centers. Insurance coverage is inconsistent, and even when available, logistical challenges can get in the way of regular participation.
That's precisely what Dr. McCaul and her team are trying to change with the Virtual A² pilot. It's designed to break down these barriers and directly bring high-quality, evidence-informed cognitive intervention into families' homes—no travel, no waiting lists, and fewer systemic roadblocks.
Building on the proven foundation of the Abecedarian Approach, Dr. McCaul's team is exploring an ambitious next step: can we deliver the same high-quality cognitive support virtually—and make it truly work for families of children with HIE?
That's the driving question behind the Virtual A² Study, a pilot program focused on strengthening early attention and executive functioning through a flexible, online format. This isn't just screen time. It's structured, high-level gameplay paired with parent-child interaction—designed to support focus, language, memory, and emotional regulation in ways that are both evidence-based and engaging.
A powerful idea is at the heart of the intervention: coaching parents to become attuned to their child's unique developmental profile—especially the intentional differences that can come with HIE. By doing so, the program aims to build cognitive skills that form the foundation for learning, adapting, and thriving over the long term.
One of the most important outcomes the team targets is school readiness and long-term independence. By starting early and supporting executive function, the hope is to empower children with HIE to navigate their developmental paths with greater confidence and capacity.
But here's the critical part: can we make this kind of support effective and practical for real families? Life with a medically complex child is already full—no one needs another overwhelming to-do. That's why feasibility is central to this study: it's about finding out whether families can actually integrate this intervention into daily routines and whether a virtual model can deliver outcomes comparable to in-person coaching.
The study includes two groups, with one arm specifically focused on children with HIE between 6 and 24 months of age. Families will go through a thoughtful, collaborative consent process to shape how data is collected and activities are delivered—ensuring the research reflects what's truly useful and manageable. There are also systems in place to securely share medical chart information across regions, allowing global participation and broadening the impact of the work.
Keeping families informed and engaged is central to the Virtual A² Study. Communication will primarily happen via email, ensuring families receive timely updates on key aspects of the study. Here's what you can expect:
You can sign up by scanning this QR code, or you can email your request and information directly to VirtualA2@neurology.wisc.edu!
Looking ahead, the goal is to expand the Virtual A² intervention and make it widely accessible to families across the country. If the study shows positive results, the next step would be to partner with early intervention programs nationwide. Each state has its own version of these programs, and by incorporating the intervention into its existing curriculum, we can help make it a seamless part of the healthcare and educational systems.
This expansion would ensure that more families can easily access and benefit from the intervention. However, before moving forward with these partnerships, the study must demonstrate that the intervention is effective.
Dr. Carrasco McCaul's hope for the future centers around shifting the focus from simply getting children into school to truly empowering them to thrive within that environment. We often talk about school readiness, but it's just as crucial to consider how children can actively engage in school, build relationships with their peers, and develop essential skills like attention, self-regulation, and problem-solving. Not every child needs to be on the honor roll, but every child deserves the tools to succeed, find their community, and make the most of their educational journey.
As for resources, there's a wealth of information to encourage cognitive development, though not much is specific to HIE. However, many of these resources can be tailored to suit the needs of individual children:
To watch the full Q&A, visit our 2025 Awareness Month Playlist on YouTube, and click the button below for our key takeaways at a glance!
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