Yana Stepanenko looked like a perfectly normal preteen as she strode into a makeshift video studio at St. Panteleimon, the main hospital in Lviv, in Western Ukraine, for an interview with a documentary filmmaker. She wore blue jeans, a fashionably oversized navy and white sweater, and white sneakers.
The first clue that all was not normal in the 12-year-old’s life would come minutes later, when she sat down before the cameras. She clutched a small red stuffed toy, kneading it constantly, almost obsessively.
When she shifted her legs, her jeans rose slightly, exposing her ankles and revealing prosthetic legs below her knees.
Yana suffers from two traumas inflicted by the war. She is a double amputee and psychologically damaged by the hell she went through – still is. She was one of the victims of the Russian missile attack on the train station in Kramatorsk, in Ukraine’s far east, on April 8, 2022, six weeks after the invasion started. The strike, which was widely condemned as a war crime, killed 63 civilians, including nine children, and wounded 150 others.
Yana was one of those injured and has spent the past year and a half trying to repair her life, both physically and mentally, with the guidance of her mother, Natalia Stepanenko, who lost a leg in the same attack, and the help of a rehabilitation medical clinic in San Diego.
While trauma cases among soldiers who endured brutal combat situations are well-known, less so is how the trauma is crushing children across Ukraine – those with physical wounds and those without; those who have lost one or more parents or relatives, and those with their families intact. War trauma, including PTSD – post-traumatic stress disorder, once known as shell-shock – has created what some trauma psychiatrists and psychologists call the silent crisis among children in Ukraine.
The Mayo Clinic defines PTSD as a mental-health disorder triggered by going through or witnessing a terrifying event, such as a near-death experience. Symptoms include severe anxiety, painful flashbacks, suicidal thoughts, a sense of detachment from family and friends, emotional numbness and nightmares. In young children, these frightening dreams may or may not include elements of the traumatic event, the Mayo Clinic says.
Ukraine’s Ministry of Health is already predicting that between three million and four million Ukrainians, many of them children, will need drugs to manage war-related mental-health problems. (The country’s prewar population was 43 million.) Another 15 million will require other kinds of psychological support. There are no estimates on how many of the trauma and PTSD victims are, or might be, children, partly because of the shortage of psychiatrists and psychologists needed for proper diagnosis. But the figure is sure to grow as the war drags on.
Scars on Their Souls, a comprehensive new war-trauma report by global think tank Globsec, whose head office is in Slovakia, said that underreported or misdiagnosed cases mean that the true number of trauma cases among adults and children could be much higher than the Ministry of Health estimates. ”Ordinary civilians who take up arms to fight in the front lines have had less than basic training,” Mandy Bostwick, a British trauma psychotherapist who was one of the report’s authors, said in an interview with The Globe and Mail. “With little or no military preparation, they are more exposed to trauma than any war in the world.”
Her Ukrainian colleague, Iuliia Osmolovska, director of Globsec’s Kyiv office, believes children’s cases of undiagnosed trauma, including PTSD, could be especially high. “It is very difficult to detect PTSD in children because they are not as verbal as adults,” she said.
Yana told her story to the documentary film director, who The Globe is not identifying because of fears of Russian retaliation, and to a Globe reporter.
The Kramatorsk attack left her and her mother unconscious. Retrieved from the rubble, they were sent to different hospitals and did not see one another for a month. Three months later, a sponsor sent Yana to San Diego for rehabilitation. At points during the video interview, when she relived her tragedy, Yana and her mother cried.
Today, Yana walks well on her protheses and uses sports-blade versions to run. She once took part in a race with other war amputees – evidence of small victories. But she is still distraught.
“I’m home most of the time,” she told The Globe. “I am doing a lot of painting and I do not have a lot of friends now. Sometimes the bad memories come but I want to forget them forever. Before I lost my legs, I wanted to become a teacher. I do not have a new dream now.”
The film director’s second interview was with Stanislaw (Stas) Lyakh, 13, who is from a village outside of Kharkiv in Ukraine’s northeast. It is the country’s second-largest city and the target of regular Russian shelling. In May, 2022, a shell wrecked the family house, burying Stas and crushing his skull. Surgeons attached a titanium plate to his cranium; he was not expected to walk again, let alone survive.
Today, he is almost fully mobile but still suffers from trauma and was mum during the documentary interview – his father, Anatolyy Lyakh, did all the talking. “That my son is standing is a miracle,” Mr. Lyakh said. “I was imagining at first that he would be attached to his bed for the rest of his life. My goal is to do my best to ensure he has a decent life.”
Ukraine is struggling with PTSD and other cases of war trauma, especially among children. There were – and are – too few psychiatrists, psychologists and psychotherapists to deal with the crisis. There were no set instructions on how to rehabilitate – or properly classify – the trauma victims. Even today, in spite of the quick, tragedy-driven learning curve, there is considerable debate on basic rehab strategies.
Should children be encouraged to relive their trauma trigger points or will that risk retraumatizing them? Which medications, if any, should be used in which cases? Are orphanages good places to rehabilitate children who lost their parents?
Mariana Romaniak, CEO of Lviv’s Ridni Charitable Foundation, which supports orphans and their caregivers, said orphanages can create more problems than they solve. She advocates adoption or foster homes for traumatized children.
“In orphanages, the children are not socialized well and there is not enough care for their mental health,” she said. “Most will not be able to adapt to normal life when they leave.”
A crucial issue is whether there is enough recognition that PTSD is more than a pure mental-health disorder. There is compelling research in recent years that PTSD has a significant biological element, which, left untreated, can lead to damaging inflammation of the bowel and other parts of the body.
“PTSD has the largest biological underpinning than any other mental-health disorder, so merely responding with psychological therapy is futile,” Dr. Bostwick said. “The need to respond to heightened levels of inflammation is crucial, since it leads to autoimmune disease and even changes to our DNA.”
Oleh Berezyuk, a psychiatrist and former Ukrainian parliamentarian who is now chief of the mental-health department of St. Panteleimon hospital, admits that he and his team have been overwhelmed by the adult and child trauma cases.
Their unit has received 15,000 trauma cases, of which 40 per cent had PTSD. “When we started, we had no idea how to treat them,” he said. “We have learned that only 20 to 30 per cent can be helped with medication. The rest have to be treated with therapy and not all therapy is appropriate. For example, patients who were captured and tortured do not trust anybody.”
Throughout Ukraine, near the combat zones and far away from them, ordinary lives are changing to deal with the epidemic of war-related childhood stress and trauma. It is equivalent to a small mobilization, with caregivers, social workers, psychologists and parents doing what they can, where they can, with whatever resources are available.
In Lviv, Unicef – the United Nations agency for children’s welfare – has set up three daycare sites, staffed with agency employees and volunteers, to try to give a sense of normalcy to displaced children who have seen war. Unicef calls the sites Spilno, Ukrainian for “together.”
At the former Lviv Film Centre, housed in a Deco-style building from the Soviet era, Spilno takes in 60 to 70 young children a day, where they do art therapy – such as painting and building objects with wooden blocks – and talk to psychologists.
Some arrive incapable of speaking. Others twitch or block their ears or eyes with their hands, as they did when the Russian bombs exploded near their homes.
Olesia Danyshenko, the Spilno supervisor in Lviv, remembers one little girl who built a tower with blocks. When it toppled, the girl burst into tears. “She was crying because it reminded her that her house was destroyed in an attack,” Ms. Danyshenko said.
One of the most remarkable transformations in the effort to save the children came last year, when Oksana Lebedeva, who had successful careers in Ukraine in marketing, media and fashion, threw it all away to open a children’s rehab centre. Called Gen.Ukrainian, the centre opened last year in suburban Lutsk, about 160 kilometres northeast of Lviv. It is housed in a modern three-storey building that was built as an orphanage but never operated as one.
Ms. Lebedeva, 37, was in Miami when the Russian invasion started on Feb. 24, 2022. It took her four days to reach Kyiv to be with her 10-year-old son. At that point, she decided to devote her life to protecting kids from the ravages of war. “Children are my weak spot,” she said.
The 50 or so children in the Gen.Ukrainian building, ranging from young kids to teenagers, are enrolled in a 21-day rehab program. All of them lost one or both parents. One girl lost 12 relatives in a single night in the brutal siege of Mariupol, in southeastern Ukraine.
“We had one boy here who was in a car when they met a Russian column of tanks,” Ms. Lebedeva said. “The Russians removed the boy from the car and then burnt his parents alive in the car.”
Ms. Lebedeva gave The Globe a tour of the building to see various therapy sessions in action. In one, the kids seemed happy, chatting away and playing games. At a teenagers’ session, most were crying as they relived their horrors. Vanui Martyrosian, a psychologist at the centre, said talking about their traumatic experiences among friends makes them realize that they are not alone and “that it is normal to be sad and angry.”
The psychologists track the children’s progress partly through their paintings. When they arrived, much of their art reflected trauma. Paintings included watercolours of severed limbs, suicides and children crying. After three weeks of therapy, many of the pictures were far less violent, even pleasant.
Ms. Lebedeva is pleased with most of the kids’ progress, while acknowledging that the centre cannot cure some of the most traumatized. She is happy that she is playing a small but crucial role in the war rehab effort.
“Here there is a concentration of grief but the progress I see gives me light in a dark time,” she said.