National Hidden Harm Project

When parents misuse substances it can and does cause serious harm to children at every age. Children whose parents misuse substances can:

experience greater risk of Foetal Alcohol Spectrum Disorders;
experience emotional and physical neglect; and
develop serious emotional, social and substance misuse problems later in life.

The experience of children living with, and affected by, parental substance misuse has become known as ‘Hidden Harm’ because these children are often unknown to services. Not all parents who misuse substances experience difficulties with parenting capacity. Equally, not all children exposed to parental substance misuse are affected adversely either in the short or longer term. However, most children exposed to parental substance misuse need some form of support.

The National Hidden Harm Project has been established by us and the Child and Family Agency (TUSLA) to inform service planning and improve services for children in relation to Hidden Harm.

Seeing Through Hidden Harm to Brighter Futures

There were five stages leading to the development of the Hidden Harm Strategic Statement – Seeing Through Hidden Harm to Brighter Futures.

1. North-South Policy

A North-South Alcohol Policy Advisory Group Subgroup on Hidden Harm was set up. There were cross-border meetings to learn from the Hidden Harm model in Northern Ireland. An all-island Hidden Harm leaflet Opening Our Eyes to Hidden Harm was produced.

2. National Steering Group

A Hidden Harm National Steering Group was set up in June 2013. This was led by:

TUSLA (the child and family agency);
the HSE National Social Inclusion Office; and
HSE Mental Health and Drug and Alcohol Services in the North West and Midlands.

The group produced ‘Addressing Hidden Harm: Bridging the gulf between substance misuse and childcare systems, Submission for the attention of Minister of State with responsibility for Drugs, Alex White, TD’ (unpublished). This led to the inclusion of Hidden Harm as a theme within Better Outcomes Brighter Futures: The National Policy Framework for Children and Young People 2014-2020.

The importance of recognising Hidden Harm and ensuring that children are identified and supported within the HSE’s Drug and Alcohol Services and by TUSLA, is included under the transformational goal of earlier intervention.

Two national practice sites were identified (County Donegal and the Midlands) to begin Hidden Harm practice working.

3. International Expert Co-opted

In October 2013, an external international expert, Ms Joy Barlow, was co-opted onto the Hidden Harm National Steering Group to inform programme direction.

4. Stakeholder Consultation

A stakeholder consultation took place in January 2014 with commissioners, researchers, service providers and practitioners from the County Donegal and Midlands practice sites. It highlighted:

the need for Hidden Harm learning and development;
inter-agency working;
assessment frameworks;
protocol for communication between services; and
clear referral pathways.

The consultation showed that three themes needed to be addressed:

how much the characteristics of alcohol and other drug use affected the capacity of the parent to care for the child;
the impact on the child; and
the impact on services.

5. Hidden Harm Practice Guide and Strategic Statement

HSE and Tusla jointly published The Hidden Harm Practice Guide and acommpanying Strategic Statement in January 2019.

These publications set out how the HSE and Tusla intend to bridge the gap between adult and children’s services, in favour of a more family-focused approach that considers the needs of dependent children and other family members.

A separate Opening our Eyes to Hidden Harm information leaflet has also been published to aid staff and other health and social services practitioners working in this area, to help affected children and families.

Minister for Children and Youth Affairs, Dr Katherine Zappone, T.D. officially launched the Hidden Harm Strategic Statement and Practice Guide on 25th January 2019, with support from Minister Catherine Byrne, T.D., Minister of State with responsibility for Health Promotion and the National Drugs Strategy. Joy Barlow MBE, a Scottish-based expert on Hidden Harm and member of the national steering group, which produced the new Tusla/HSE Hidden Harm documents for staff, was a keynote speaker at today’s event. Speaking on behalf of the HSE was Joe Doyle, Planning Specialist from HSE National Social Inclusion Office and Dr Aisling Gillen, National Service Director from Tusla.

6. Training

Hidden Harm eLearning was developed by the HSE and TUSLA, with input from the community & voluntary sector on recognising and responding to the impact of parental alcohol and other drug use on children.

This programme is relevant to all staff working with parents, children, young people or families who may be affected by problem alcohol and other drug use. This includes HSE, Tusla, and community/voluntary sectors.

The aim of the programme is to support staff to increase their awareness of and response to Hidden Harm, which is the experience of children living with and affected by parental problem alcohol and other drug use. The module aims to encourage all services and stakeholders to work together to support the family. The module includes guidance from a Parents perspective and from professionals working in the Voluntary and Community sector, the HSE and Tusla-Child and Family Agency. It is based on the HSE/Tulsa Practice Guide; Hidden Harm-Seeing through Hidden Harm to Brighter Futures (2019). The topics covered are the impact of Hidden Harm, the voice of the parent, working together and Hidden Harm in practice. By the end of the module the learner will be able to:

Recognise the impact of Hidden Harm on children and young people
Support the parent to limit the impact of problem alcohol and other drug use on the children or young people
Work in partnership with parents and other services to meet the needs of the child or young person.

The eLearning is available on HSELand for HSE, TUSLA, and community & voluntary sector staff. To access the eLearning:

Log into www.HSELand.ie using Google Chrome
Follow the instructions to register as a new user, or use your existing HSELand log in (you may have this from the mandatory Children First training)
Click on ‘search’ and type in Hidden Harm

A one-day skills-based training day to complement the eLearning was completed in 2020. The aim of the one-day skills-based training is to provide an environment to colleagues from HSE, TUSLA and the community & voluntary sector to consider the impact of the issues of Hidden Harm on their practice and to clarify the benefit to the child, parent and family, of effective working together. This training will be piloted in Q.4 2022.