GAZA CITY, Gaza (AP) — Suzy Ishkontana hardly speaks or eats. It’s been two days since the seven-year-old girl was pulled from the rubble of what was once her family’s home, destroyed amid a barrage of Israeli airstrikes. She spent hours buried in the wreckage as her siblings and mother died around her.

Children are being subjected to extensive trauma in Israel’s bombardment of the Gaza Strip. For some, it’s trauma they’ve seen repeatedly throughout their short lives.

This is the fourth time in 12 years Israel and Gaza’s Hamas rulers have gone to war. Each time, Israel has unleashed heavy airstrikes at the densely populated Gaza Strip as it vows to stop Hamas rocket barrages launched toward Israel.

According to Gaza health officials, at least 63 children are among the 217 Palestinians who have been killed in Gaza since the latest conflict between Israel and Hamas began on May 10. On the Israeli side, 12 people have been killed by Hamas rockets, all but one of them civilians, including a 5-year-old boy.

Israel says it does everything it can to prevent civilian casualties, including issuing warnings for people to evacuate buildings about to be struck. As Hamas has fired hundreds of rockets into Israel, most of them intercepted by anti-missile defences, Israel’s military has pounded hundreds of sites in Gaza, where some 2 million people live squeezed into a tight urban fabric.

Videos on social media from Gaza have shown the grief of survivors from families wiped out in an instant.

“They were four! Where are they? Four!” wailed one father outside a hospital after learning all four of his children had been killed. Another showed a young boy screaming “Baba,” as he ran to the front of the funeral procession where men were carrying his father’s body to burial.

The Ishkontana family was buried under the rubble of their home early Sunday, after massive bombing raids of downtown Gaza City that Israel said were targeting a Hamas tunnel network. The strikes came without warning.

Riad Ishkontana recounted to The Associated Press how he was buried for five hours under the wreckage, pinned under a chunk of concrete, unable to reach his wife and five children.

“I was listening to their voices beneath the rubble. I heard Dana and Zain calling, ‘Dad! Dad!’ before their voices faded and then I realised they had died,” he said, referring to two of his children.

After he was rescued and taken to the hospital, he said, family and staff hid the truth from him as long as they could. “I learned about their deaths one after another,” he said. Finally, Suzy was brought in alive, the second-oldest of his three daughters and two sons, and the only survivor.

Though she had only limited physical bruising from her seven hours under the rubble, the young girl was in “severe trauma and shock”, said pediatrician Dr Zuhair Al-Jaro. The hospital was unable to get her the psychological treatment she needs because of the ongoing fighting, he said.

“She has entered into a deep depression,” he said. Only today, he said Tuesday, did she eat something after she was allowed briefly outside the hospital and saw her cousins.

As her father spoke to the AP, Suzy sat on the bed next to him, silent and studying the faces of the people in the room but rarely making eye contact. When asked what she wanted to be when she grew up, she turned away. When her father started to answer for her, saying she wanted to become a doctor, the girl began sobbing loudly.

Ishkontana, 42, who recently stopped working as a waiter because of coronavirus lockdowns, said Suzy is smart and tech-savvy and loves smartphones and tablets. “She explores them, she has more experience dealing with them than I do,” he said. She also loves studying and would gather all her siblings into a play “class,” taking the role of their teacher, he said.

The Ishkontanas were just one family hurt that day.

The strikes Sunday targeted Hamas tunnels running under Gaza City, the Israeli military said. The warplanes pounded al-Wahda Street, one of the city’s busiest commercial avenues, lined with apartment buildings with stores, bakeries, cafes and electronics shops on the ground floors.

Three buildings collapsed, and multiple people from at least three families were killed. In all 42 people died, including 10 children and 16 women.

Lt Col Jonathan Conricus, an Israeli military spokesman, called the situation that led to the deaths “abnormal”. He said in one location the airstrikes caused a tunnel to collapse, bringing houses down with it, “and that caused a large amount of civilian casualties, which were not the aim”.

He said the military was analysing what happened and “attempting to recalibrate” its ordnance to prevent a reoccurrence.

He said the bombing campaign targeting tunnel networks would be expanded to more areas of Gaza and that the military tries when possible to hit tunnels under roads rather than under houses.

Israel and Hamas have fought similar conflicts in 2009, 2012 and 2014, each time wreaking heavy destruction.

The Norwegian Refugee Council said that 11 of the children killed so far in this war had been going through its psycho-social programmes helping children deal with trauma — a sign of how children repeatedly are victimised by the violence. Among them was eight-year-old Dana, Suzy’s sister.

“It’s the fourth time for many of them to experience” bombardment around their homes, said Hozayfa Yazji, the refugee council area field manager.

Parents in Gaza desperately try to calm their terrified children, as bombs rain down, telling the youngest ones it’s just fireworks or trying to put up a cheerful front.

The violence “will of course affect the psychology of these kids”, he said. “We are expecting that … the situation will be much worse and more children will need more support.”

The refugee council works with 118 schools in Gaza, reaching more than 75,000 students through its Better Learning Program. The programme trains teachers to deal with traumatized children and organises fun exercises to relieve stress. It also does home-checks on children to provide help.

The council’s secretary-general, Jan Egeland, called for an immediate ceasefire, saying, “Spare these children and their families. Stop bombing them now.”

But he said, longer term, an end to the blockade on Gaza and occupation of Palestinian territory is necessary “if we are to avoid more trauma and death among children”.