Identifying Data

Name D.A
Age 6-year-old
Sex Male
No. of siblings 3
Birth order second
Religion Islam
Family System Nuclear
Institute initials S.S.S
Source and Reason for Referral
The client’s parents brought him to the institute and he was referred to a trainee
clinical psychologist by his school teacher. The reason of referral as such behaviors like
piercing, lack ofsocialization, lack of eye contact, aggressive behavior, tongue rolling and
tapping.
Table 1.1
Presenting complaints reported by parents
‫دورانیہ‬ ٰؑ‫مسائل‬
‫ سال‬3‫تقریبا‬ ‫باتعں کی طرف دھیان نہیں دیتا‬
‫ سال‬2 ‫تقریبا‬ ‫بہت جلدی غصہ میں آجاتا ہے‬
‫ سال‬3 ‫تقریبا‬ ‫ایک جگہ ٹک کر نہیں بیٹھتا‬
‫سال‬5‫تقریب‬ ‫کہنا نہیں مانتا باتعں کو سمجھ نہیں پاتا‬
Table 1.2
ٰٰٰٰٰٰٰٰٰؑؑؑؑؑؑؑؑؑPresenting complaints reported by teacher
‫دورانیہ‬ ٰؑ‫مسائل‬
‫ ماہ‬3‫تقریبا‬ ‫بات نہیں مانتا جماعت میں نہیں بیٹھتا‬
‫ ماہ‬2 ‫تقریبا‬ ‫بھت چیحتا چالتاھے‬
‫ ماہ‬3 ‫تقریبا‬ ‫کام کی طرف دھیان نہیں دیتا‬

History of present illness

The client’s parents reported that child’s problems were noticed when he was 3-year-
old.He had problems maintaining eye contact and did not respond to commands. Initially,
these problems were considered normal but over time the problems did not get normalized.
 After 1 year school teacher reported complaints such as lack of social interaction,
aggressive behavior on repetition of commands and lack of eye contact, piercing when tried
to speak. Client’s parent reported that client faces difficulty in the morning routine and his
interaction was also very rare with siblings.

Initial Observation
The child was 6 years old boy. He was dressed neatly and his hair was combed.
Overall hygiene was maintained. He had no eye contact. His mood was normal and he
seems energetic. He had no orientation. The child was observed in multiple settings,
such as classroom and lunch time and it was non participant observation, during class
child was sitting on chair uncomfortably. He was tapping and moving on his chair. The
child was not done his work properly. When trainee clinical psychologist invited him
for session he followed her and Rapport building with child was not an easy task. His
language and speech was not developed properly .During session it was observed that
he become frustrated so easily. It was also observed that his fine and gross motor skills
are also not developed properly as he cannot hold pencil properly. Observation also
made inplay ground and it was observe that he was not socialized. He likes to play
alone with alone with football it seems that he was happy in playground.

Background Information
Family History
The client belonged to a middle-class family and was living in a nuclear
family system. Client was living with his mother, and 2 siblings. Parents reported that
the environment ofthe home is good and peaceful.

Father. The client’s father was 43-year-old. He has done matriculation. He was working in
Dubai. Therelationship of client with her father was good and strong. The client’s father
was a soft-hearted man.
Mother. Client’s mother was 37-year-old. She was a housewife. The relationship between
the client andhis mother was satisfactory. The mother spends more time with the client’s
younger siblings. The clients’ parents were cousins.
Siblings. The client has two siblings, one brother of age 3 and one sister of age 2 years. The
interaction ofthe client with siblings was rare. The client has no interest in playing with
 siblings. There was no interactive relationship between the client and his siblings.

Personal history

Client’s parents reported that client’s birth was normal. There were no
complications during pregnancy and birth. Client weight was below average at the
time of birth. His milestone development was not adequate. His sitting, crawling,
speech, and walking were delayed Bladder and bowl controlled at the age of 4. In
verbal development, the client was not able to produce proper sounds. It was also
reported that the client had weak bones so he cannot perform fine and gross motor
tasks properly.

Table 1.3
Delayed Milestones Reported by Client’s Mother
Milestones Achieved Age of Normal age of
Milestones achieving
First Cry After birth After birth

neck Holding 3 months 2-3 months

Sitting 8 months 7 months

Crawling 8.5 months 6-8 months

Walking 1.4 year 12 months

Speaking(1-word
1 year 10 months
syllables)

Complete speech Not yet 2 years

Toilet training 5.8 years 4-5 years

Education history
After 1 year of school, the teachers' complained about the child behavior Such as Lack
of social interaction, poor eye contact, lack of interest in activities, aggressive
behavior and piercing. The School teacher recommended him to a special education
school because the child wasn’t able to fulfill the requirements of the school like other
age fellows.
General Home Environment
General Home environment was healthy and satisfactory.

Father Mother

D.A

Brothers Sister

Parents Healthy Relationship

Brother Weak Relationship

Sister

Medical History
No severe or problematic medical history reported by the client’s family.
History of Psychiatric Illness in Family
A history of serious Psychiatric illness was not reported by the client’s family.
Psychological Assessment
Psychological assessment is a testing method that uses a number of
techniques to find hypotheses about individuals and their behavior, abilities, and
personality (Framingham 2016). Formal and informal assessment was carried out to
assess the presenting complaint.
Informal assessment
 Clinical Interview
 Behavioral observation
 Reinforcer Identification
 Subjecting Rating
Clinical Interview‫ٰؑ۔‬A clinical interview is a conversation between a clinician and a patient
that is typicallyintended to develop a diagnosis. It is a "conversation with a purpose" that
can be structured, semi-structured, or unstructured. Emphasis is placed on open-ended
questions with the focus being on the patient and not the clinician. Clinical interviews are
typically used with other measures and methods to diagnose the patient.
Behavioral observation. is a form of informal clinical assessment that recording te
behavior of client in different areas of functioning that the observer is interested (Bakeman
2000).
Child was 6-year-old boy. The child has average height and weight. He was earing neat nd
clean dress and was appropriate to weather. His hair was perfectly combed. He had limited
and no social contact with his peer group. He was just responded to common instruction like
sit down, come with me on repetition of commands. The client behavior was clearl strange
or unusual for her age in which includes tapping and clapping.The child had no verbal
response and he remained silent during the session. He did not maintain the eye contact and
had poor concentration. He had no orientation of space, person and time. By observation it
had been clear that the client performs some repetitive acts. He showed some interest in the
art activities and he liked to play with toys and blocks.
Classroom Observation. In classroom, the client was not interested in coloring and
matching activities and teacher had to repeat again and again her instructions to follow by
the client. He forgot the things immediately after performing them. Client had very poor
gripped over pencils.
Playground Observation. Client showed much interest in playground activities. He was not
interested in 1 game. he started running and then quite that start cycling after few minutes
started sliding. Throughout the time he clap and produce different non syllable sounds.
Session Observation. During the session, client didn’t make eye contact and didn’t show
interest in activities and started clapping and tapping his hands on and off. He was drawing
random lines on page.
Visual Analogue (Subjective Ratings of the Symptoms). Visual analogue can be
used for subjective ratings of mood, emotion, distress, or other sensations. Clients
simply rate the intensity of the sensation on a scale from 0-10 (McQueen, 2008).
Subjective ratings of the child’s symptoms were rated by the mother and the trainee
clinical psychologist by using 0-10 rating scale. In the ratings, 0 = no problem, 5 =
average problem and 10 = severe problem.
Table 1.4
Subjective rating of the client’s problems as reported by the mother
Problematic Areas Pre-Rating
Poor eye contact 1

Inattention 2

Forget the learn task 1

Lack of socialization 1

Tapping 9

Reinforcer Identification. Identified the client’s reinorcer, because identification of

positive reinforce is important in any behavior treatment program, the identification of
positive reinforcer is a necessary first step in the process of establishing an appropriate
change in behavior. (Peterson, 2013)
Reinforcer identified through history given by caregiver, and observing child, and also
asked by the teacher and arranged them according to priority and used these reinforcer
during session for goal achievement and for rapport building.
Table 1.5
Client’s Reinforce with Type and Priority
Reinforcer Type Priority

Colors Activity 1st

 Praises,Very Social 2nd

Good, High Five

Toy Tangible 3rd

Formal Assessment Tools

 DSM 5 Criteria Checklist of Intellectual Disability Disorder

 Childhood autism rating scale (CARS)

DSM 5 Criteria Checklist of Intellectual Disability Disorder

Table 1.6
DSM 5 diagnostic criteria checklist for Autism Spectrum Disorder

Deficits in social emotional reciprocity

Deficits in verbal communicative behaviors

Deficits in developing, maintaining and

understanding
Relationships

Repetitive or stereotyped motor movements, use of objects

or
Speech
Highly restricted fixated interests that are abnormal in
intensity

and focus

Hyper or hypo activity to sensory input or unusual interest in

sensory aspects of the environment.
Symptoms must be present in the early developmental period.

Symptoms cause clinically significant impairment in social,

occupational and other important areas of current functioning.
Portage Guide to Early Education (PGEE)
Test Administration
Portage Guide to Early Education was developed by Bluma, Shearer, Frohman
and Hilliard (1976). Its Urdu version which was translated by Ministry of Education
and Social Welfare, Islamabad, which was administered on the child in an
assessment room. It consists of six areas. Its purpose was to assess the degree to
which child’s language, motor, social, cognitive and self-help skills were developed
and his functional age. Cognitive area was directly administered on the child
whereas; questions related to other areas were asked from mother. Some items
related to motor area were also practically performed by the child. It took almost 30
minutes of 2 sessions to complete the guide (See Appendix A1).
Results
Quantitative Analysis
Table 1.7
Showing developmental age in years and months
Area Developmental Age
In Months In Years
Self-help 48.24 4.02
Motor 63 5.25
Cognitive 36.6 3.05
Language -- --
Socialization 29.64 2.47
Qualitative Analysis. The table showed that child’s developmental age is showing
high discrepancy in all areas of Portage Guide to Early Education as compared to
his chronological age. His most little developed areas are cognitive and language.
His self-help area is also least developed. His motor is well developed as compared
to other areas but still less developed as compared to his chronological age.
D.A’s chronological age is 6 years that equals to 72 months. There is a
discrepancy of 42.36 months in his chronological age and current functioning
age in the domain of socialization. This is the least developed domain of the
child’s functioning.
 For the domain of self-help, the child is currently functioning at 48.24
months and there is a discrepancy of 23.76 months. This is almost half of what
is expected from him according to his chronological age. In the cognitive
functioning the current functioning age is 36.6 months and the discrepancy is
of 35.4 months. The child’s current function age for the domain of motor
skills is 48.6 months while the discrepancy is of 23.4 months. The child had
no speech so language domain can not be administered on him.
Childhood Autism Rating Scale (CAR). The Childhood Autism Rating Scale (CARS) is a
behavior rating scale intended to help diagnose autism. CARS was developed by Eric
Schopler, Robert J. The scale was designed to help differentiate children with autism from
those with other developmental delays, such as intellectual disability.
The Childhood Autism Rating Scale–Second Edition (CARS2) is a 15-item rating
scale used to identify children with autism and distinguishing them from those with
developmental disabilities. It is empirically validated and provides concise, objective, and
quantifiable ratings based on direct behavioral observation.
Table 1.8
Child Autism Rating Scale scoring

Area Raw Score Category

Relating to people 3 Severely Abnormal

Imitation 2.5 Moderate

Emotional Response 3 Severely Abnormal

Body Use 2 Mild

Object Use 2.5 Moderate

Adaptation to change 2 Mild

Visual Response 1.5 Age Appropriate

Listening Response 3 Moderate

Taste, smell, and touch response and use 3 Moderate to Severe

Fear of Nervousness 2 Mild to Moderate

Verbal Communication 4 Severe

Non-Verbal Communication 3 Moderate to Severe

Activity Level 3 Moderate

Level of Consistency of Intellectual

Response 3.5 Severely Abnormal

General Impressions 3 Moderate Autism disorder

Total Score 41 Moderate to severe Autistic

Qualitative Analysis. Total score of the child on CARS' categories came out to be 41 which
showedthat the child was Mild to Moderate Autistic. a. Maximum score "4" of the child was
found in adaptation to change .Client showed extreme resistance to change the routineor
engaged in new activities. He showed same pattern of behaviour and repetitive activities.

Diagnosis
The symptoms suggest the client is suffering from with Autism spectrum
Disorder (299.OO/F84.0)
Prognosis

The term prognosis refers to making an educated guess about the expected outcome

of any kind of health treatment, including mental health, in essence making a prediction of

the process an individual may have to go through in order to heal and the extent of healing

is expected to take place (Rudlin, 2020). A prognosis is based on number of factors. It

includes the type of problem, the duration of the problem, personal strengths, weaknesses

and the availability of support system.

Case Formulation

The client was 6 years old with complaints of lack of verbal communication,
inability to communicate his needs to others, hand flipping, not maintaining eye contact, off
seat behavior atschool speech problem, difficulty in reading and writing, poor socialization.
The child was observed in different settings. To assess the child’s problem CARS, along
with behavioral observation and clinical interview were conducted. The case was
formulated according to bio psychosocial model. According to biological predisposing
factor it was reported that the child was so tiny and weak and have a very low birth
weight at the time of birth and cousin marriage of the parents. According to American
Psychiatric Association (2013), the essential features of Autism Spectrum Disorder (ASD)
are persistent impairment in reciprocal social communication and social interaction; and
restricted, repetitive patterns of behavior, interests, or activities. The precipitating factor
was the child’s delayed milestones such as his language problem. Precipitating factors are
the refusal of parents for special school and toxic environment of the client. These factors
were the stressor. Perpetuating factor are low concentration of the client. The mother of
the child reported that she ignored him often because of her busy routine and in school it
was observed that he remainedsilent as he was under the pressure of teachers and he had to
follow rules which might be his maintaining or perpetuating factors. The psychological
features of autism spectrum disorder suchas lack of interest in social interaction in the first
year of life, and unusual social interactions (e.g., pulling individuals by the hand without
any attempt to look at them), and unusual communication patterns (e.g., knowing the
alphabet but not responding to own name as in the present case) can be a result of child’s
idiosyncratic approach to his social environment, not being able to understand what social
behavior is required from him (Charman, & Stone, 2012).Overprotective parenting in low-
risk environments may have negative consequences for the psychosocial development of
children and youth. Though not well studied, a number of different bodies of literature can
be used to speculate on the reasons for overprotective parenting and the impact it has on
children (Gagnon 2019). The protective factors were the continuation of therapy.
 Case Conceptualization

Presenting
Complaints
Tapping
Lack of eye contact
Assessment Tools
Lack of social
interaction Behavioral observation

Piercing Reinforcer Identification

Clinical interview
Baseline Chart

Symptoms Rating

Scale
Predisposing Precipitatin
Factors g Factors Maintaining factor Protective Factor
Negligence and busy delayed milestones Negligence of Continuation of
routine of mother such as his languagemother, School therapy
Low birth weight problem environment

Lack of socialization,
tapping

Suspected Diagnosis Management Plan

Autism Spectrum Disorder  Rapport Building
 Behavior Modification
Outcomes  IEP
30-40% improvement  Occupational Therapy
 Management plan
Short Term Goals
 Rapport building. will be done with client by developing relationship of mutual interest
by involving the client in different activities. But it was somehow difficult as the child was
least interested in people other than his mother. But finally the therapist built rapport.
 Individualized Educational Training Plan. will devise for functional skills such as
perquisite skills, cognition, socialization, language, motor and self-help skills.
 Behavior Modification. will use with the child in order to teach the behavior skills.
These techniques will used in this regard are as follows:
 Response Prompts (physical, verbal). will be used to maintain eye contact,
scribbling, to eat with spoon without help, to do easy moves on asking like clapping
and jumping.
 Positive Reinforcement. will be used to maintain eye contact, to show the picture.

 Physical Restraint. will be used to teach the client to wait for 5minutes
 Occupational Therapy/ Play therapy. The client was given occupational therapy in
which he was engaged in games in order to increase his sensitivity. His touch sensation
was increased by asking him to touch the toys and put it in the box. His visual sensation,
auditory sensation was also used.

Long term goals

 To increase the individual functioning of client
 Continuation of short-term goals
 Following individualized educational plan
Rapport building. is the trustworthy relationship between the client and the therapist.
Different techniques are used in rapport building to build the rapport. There is a technique
butterflies in the stomach are used to build the healthy relationship with the client.

Behavior Therapy (Positive Reinforcement). As the client having difficulty in interacting

with others, for this purpose positive reinforcement from behavior therapy was used.
Therapist first identifies the reinforcer of the child. He reinforced the child on every
desirable behavior for example, when say hello to his peers for the first time he was
reinforced with the chocolate, and then after playing with his friends for a while he was
 further reinforced with a toy. By using the same way, the therapist gradually improved the
client’s interaction with others.
Prompting. Prompting are the verbal cues given to the client to remind them to complete the
task theyare asked for. Verbal, physical, and gestural prompts were used with the client
during sessions for the targeted behavior such as using different voice tones (Damag, 2019).

Individualized Training Plan (ITP). Individualized training plan is a written statement of

the educational program designed to meet child’s individual needs. The goal is to set
reasonable learning goals for a child (Nichy, 2013). In the present case Individualized
Educational Plan was designed according to client’s needs and current of functioning.
Following areas were covered in IEP plan of the client i.e., fine motor skills, activities of
daily living, gross motor skills and sensory protocol.
Psycho-education. Parent counseling was a very essential component of the therapy.
“Patients and their families were given a preliminary briefing on the problems of the patient
in the hopes that developing a fundamental understanding of the illness they would be
willing to commit to more ling term involvement” (Bauml,2014). The client’s mother was
psych educated regarding the client’s problem in different areas. The client’s mother was
comfortable with the mode and nature of session. Mother was also informed that her support
and cooperation was important in client’s betterment and for future improvement
(Lukens,2004).

Physical Restraint. Physical restraint was a punishment procedure in which contingent on a

problem behavior, the therapist holds the part of the client’s body that is involved in the
behavior as a consequence, the client is physically restrained from continuing to engage in
the problem behavior (Miltenenberg,2011). This techniquewas applied on the client to
reduce tapping hands and making strange noises/sounds from the mouth. When the client,
tapped his hands, the therapist responded by holding the client’s hands down for 20
seconds. Similarly, when he made sounds from his mouth, the therapist responded by
holding his mouth for 10seconds. While being physically restrained, the client could not
engage in the problematic behavior
Analogue (Subjective Ratings of the Symptoms)
Subjective ratings of the child’s symptoms were taken by the mother and the
trainee clinical psychologist by using 0-10 rating scale in order to see improvement
after applying therapeutic intervention.
Post Assessment. Post assessment was done on Behavioral Observation and
Subjective post Ratings by mother on presenting complaints.

Table1.9

Ratings on problematic areas of the client’s mother at pre and post-treatment

level on a10 point scale.
0= no problem, 5 = moderate, 10= severe problem

Problematic Areas Pre-Rating Post-Rating

Poor eye contact 1 4

Inattention 2 4

Forget the learn task 1 2

Lack of socialization 1 2

Tapping 9 5

Slow motor movements 2 4

Graphical representation of subjective ratings

10
9

Pre-Rating
Post-Rating

3
2

Poor eye inattention Forget the Lack of tapping Slow motor

contact learn task socialization movements

Summary of Therapeutic Intervention

According to the presenting complaints of the client different therapeutic
interventions were used. In the first two sessions rapport was built with client using
rapport building techniques, he also learned to maintain eye contact for some time.
Positive reinforcement was used for maintaining his morning routine. Group therapy
and play therapy was used for enhancing his interaction with peers. Speech therapy was
used for resolving his issues related to speech. His parents were psychoeducate about the
client for normalizing his problematic behavior at home. In the last session, we look
upon the task that proceed throughout the sessionsand the exercises that were continued
and helped the client in maintaining the positive behavior.

Recommendations
Proper guidance from his parents towards him will helpful for his speedy recovery
Limitations
 Lack of speech was also a hurdle in communication.

 Limited information was available

Suggestions
 Further sessions should be arranged to work on the problems of the client.

 Client was very interested in sports activities. So, sports activities should be
planned to improve his motor skills and attention.
 Speech therapy will be helpful for the client as he had very little speech.

 Parents should also guide to continue the planned activities in the same
manner in homebecause it will help to improve the deficiencies earlier.
 Session Report

Session 1-2
Goals:
 To build rapport with client.
 To find out the presenting complaints.
 To find out the interest of client in the different activities.
Session Structure. Client’s appearance was appropriate. He had an impaired social
interaction. He had poor eye contact. He was failed to orient to a speaker. Moreover,
he felt discomfort with physical touching. Client had impaired communication. He
had lack of imitation. His tonal quality of speech was unusual or inappropriate. His
on-seat behavior was tried to maintain in the entire session. Client was showed the
resistance towards the therapist. That is why, rapport was not properly developed with
client. However, with the help of observation, client’s presenting complaints was
noted. In this way, client was not interested in any activity. At the end of session,
client was intentionally left the room and non-verbally good bye to therapist.

Session 3-4
Goals:
 To build rapport with client.
 Worked on on-seat behavior
 To find out the interest of client in the different activities.
Session Structure. In this session, client was not so cooperative. Trainee Psychologist
found his reinforcer to develop his interest and increase his on-seat behavior. During the
session Trainee Psychologist tried to develop strong rapport with client. At the end of
session, Client was engage in coloring. Portage guide to early education was administered on
the client in this session. In this session, the child was not in good mood and was showing
irritating behavior. Therapist gave command to play with blocks and doing the coloring activity.
Stickers were awarded to appreciate him. Parents were psycho educated and change in client’s
behavior.
Session 5-6
Goals:
 Revise previous tasks
 CARS was administered.
 Eye contact maintaining exercises
 Command Following
 Prompting
Session Structure. In this session trainee psychologist worked on maintaining eye contact.
Client maintained eye contact and cooperates with therapist. In this session, therapist worked on
the child to enhance attention by using physical prompting technique i.e. asked about his body
parts and this trail was done 3 times. Therapist positively reinforced the child and appreciated his
by saying good job and clapping. The therapist work on child’s attention span. Then therapist
ends the session and gave some candies as reinforce.
Session 7-8
Goals:
 To build rapport with client.
 Conduct IEP plan
 Apply social reinforcement technique

Session Structure. In this session Trainee Clinical Psychologist revised his previous tasks.
Client was reinforced on good attempts. He increased his on-seat behavior and partially
maintained eye contact. Trainee Psychologist taught him to draw circle with physical and
verbal prompts. Trainee Clinical Psychologist used reinforcement to get better outcomes.

Session 9-10
Goals:
 IEP plan continue

 Work on listening

Session Structure. In this session, therapist was doing the activity with the child. The
purpose of the activity was to help the child to listen. This activity improved attention,
concentration, memory and learning skills. This technique helped trainee clinical
psychologist to maintained client’s attention span and understand the command
following.

Session 11-12
Goals:
 Revision of previous activities
 Social Skills
 Learn manners and gratitude

 Termination
Session Structure. This session was conducted for the purpose of social skills like how
to hand shake with others and how to say good bye to others. So the main purpose of this
activity was to teach social mannerism. Social learning was done in this session. This
session was based on group therapy. The command was given to the child for handshake
to all children’s who were present in the group. Therapist said well done, good boy and
the child was very happy. The session was done. Previous Tasks were revised. The end
of therapy was positive experience with a long lasting impact on both the client and
therapist. Successful termination was done and thegoals were achieved. Specified time
for working was ended.
 References

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Werry JS, Wollersheim JP: Behavior therapy with children. A broad overview. J

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Individual Training Plan

Name: D.A Gender: Male Age: 6 years

Diagnosis: Autism Spectrum Disorder

Area Target Current technique Material Strategies Achiev-

Objective Functioning ed

Socialization To He doesn’t Positive Rein- Candies, First the 20%

maintain maintain eye- forcement, mobile therapist will

eye contact contact physical prompt put her hands

on the sides

of clients’

Cognition To scribble He can hold Physical prompt, Paper, The physical 25%

on paper pencil but verbal prompts crayons prompt will

doesn’t provided to

scribble the wrist then

to the arm

and at the end

only verbal

prompt will

be provided
Socialization To wait for he can wait Physical Chair, table Starts from 2-

5minutes only for 2min restraint Toys 3 min then 3- 30%

for food to hardly 4 and then 4-

serve 5.

Self-help To eat with He can eat Physical Spoon, plate, Starts from

skills spoon with help Prompts, rice physical 35%

without prompt and

support then move to

fade

language To show He doesn’t Positive Candies, Will start 20%

something comply to reinforcement cards of car from physical

when commands Response prompt and

asked to do prompts then move

so towards

verbal

Cognitive To do easy He doesn’t do Response Will start 35%

moves on movements prompts from physical

asking when asked to prompts and

do so then verbal

prompts
motor jumping He can walk Response Jumping Will start 30%

straight but prompt(physical, trampolin from jumping

can’t jump verbal) with support