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In addition medications kidney failure order 400mg asacol with mastercard, because the clinical parameters of an influenza pandemic are as yet uncertain medicine 95a buy discount asacol 400 mg online, increasing the difficulty of predicting survival or duration of critical symptoms medicine 003 buy 800 mg asacol fast delivery, the specifics of the clinical ventilator allocation protocol may evolve as data about the pandemic viral strain 36 Chapter 1: Adult Guidelines become available during a pandemic medications safe in pregnancy buy asacol 400 mg free shipping. Nevertheless, the government has a duty to plan for foreseeable emergencies, and this work product embodies the current, best efforts at an effective, fair plan aimed at saving the most lives in an influenza pandemic where there are a limited number of available ventilators. Distributive Justice A just system of allocation must be applied consistently and broadly to be fair to all. In addition, the same allocation system should be implemented across the State, and the decision to implement clinical ventilator allocation protocols must be authorized by the State. The timing and content of a just allocation system cannot fall to individual hospitals, but must be coordinated with the State. A just and equitable health care system cannot allow for more expansive access at a prestigious private facility and more restrictive access at a community or public hospital. Cooperative agreements to pool scarce resources among local hospitals may help alleviate initial shortages. The allocation of ventilators from State and federal stockpiles must take into account the ratio of local populations to available resources, and supplement those resources accordingly. Ethically sound responses to a public health emergency must not exacerbate disparities in access to care. Rather, planners must designate appropriate resources for the most vulnerable, whom are most likely to suffer the greatest impact in a public health emergency. Transparency Any just plan allocating ventilators requires robust efforts to promote transparency, by seeking broad input in the design of the plan and educating the public. The Department of Health and the Task Force will continue to publicize the Guidelines, and share them with health care leaders and the community. The general public’s values must be evaluated and included, because it is the public that ultimately must live with the outcomes of the Guidelines. The assessment of public comment and feedback has been integrated into the Guidelines and contributes to the development of a just allocation process. The ongoing process of obtaining and incorporating feedback helps promote public trust in the Guidelines. Triage Decision-Makers: Officer or Committee A physician attending to a patient should have neither the main nor the sole responsibility for determining whether his/her patient is eligible for ventilator therapy. Instead, a triage officer or triage committee makes the determination about a patient’s level of access to a ventilator. Neither a triage officer nor any members of the triage committee should have any direct contact with patients. A patient’s attending physician provides a patient’s clinical data to a triage officer/committee who examines the data and makes the decision whether a patient is eligible for (or continues with) ventilator therapy based on the clinical ventilator allocation protocol. Use of a separate person/team to triage is essential for an effective clinical ventilator allocation protocol for several reasons. First, this framework permits attending physicians to 37 Chapter 1: Adult Guidelines fulfill their obligation to care for their individual patients without facing a conflict of interest; they can advocate for their patients and not also be responsible for deciding to withhold or withdraw ventilator treatment. Second, separating the attending physicians from the triage decision-makers also ensure that the person(s) in this role is a senior/supervisory clinician. This person(s) will have access to real-time information, which helps with balancing the need for ventilator treatment versus resource availability. Further, this person(s) will make allocation decisions consistently across a group of patients. Finally applying role sequestration enhances the capacity for maintaining professionalism by helping to decrease burnout and stress for health care providers providing direct critical care during the epidemic and for the decision-makers, and for all clinicians to sustain their integrity as healers. It is probable that patients in need of a ventilator are individuals who may be familiar to a triage officer/committee and efforts should be made by the facility to ensure that a triage officer/committee does not have access to the identity of patients. To minimize decision bias and potential conflicts of interest, a triage officer or triage committee member should recuse him/herself where appropriate. In the event a recusal occurs, the facility should have plans for qualified staff – but not a physician currently attending to patients – to temporarily fulfill the responsibilities of a triage decision-maker. While the Draft Guidelines suggested the use of a triage officer, these revised Adult Guidelines acknowledge that because acute care facilities differ in size and available resources, it is not appropriate to conclude that a triage officer is the best model for all facilities. Thus, the Task Force recommended that individual institutions should determine whether a triage officer or triage committee is appropriate. For either a triage officer/committee model, the individual(s) should have the appropriate background and training to apply the protocol with confidence. The benefits and drawbacks of both paradigms are presented below and each hospital should determine which model best suits its needs. Because one individual is in charge of these crucial decisions in normal, non-pandemic conditions, it is logical to utilize the same model for the Guidelines. Ideally, an intensivist may be the best specialist to be a triage officer, because this type of physician has more experience with critical care patients. The use of a triage officer ensures consistency and efficiency because only one person makes the triage decisions. In a pandemic, an overwhelming amount of patient data may need to be examined, and a triage officer may experience burn-out. Rotating a triage officer responsibility among a small group of people could 68 See Centers for Disease Control and Prevention, Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators during a Severe Influenza Pandemic or Other Public Health Emergency,17 (July 1, 2011). In addition, if a triage officer is unable to perform his/her duties, there is the question of who makes the triage decisions. A triage team could help decrease burn-out and stress for the triage decision-makers, who could share the responsibility and obtain support from other members. In addition, inclusion of individuals from outside the medical or clinical community, such as ethicists or religious/pastoral care representatives, in the triage committee could provide a perspective from “outside the medical profession,” which may be comforting to the general public. However, the contribution of these non-medical members may be limited because the triage decision is based on clinical factors alone. Shortcomings of a triage committee include questions related to how to resolve 70 disagreement about triage decisions between members and how decisions are made if all members are not available during the pandemic. In addition, staffing may be a problem, particularly in smaller community hospitals that may not have the resources to form a triage committee. Pitfalls of an Allocation System In building a clinical ventilator allocation protocol, there are pitfalls that an allocation system must avoid. Emergency planning must not serve as a means to resolve long-standing disparities in health care access. For instance, an allocation system does not alleviate the need to provide adequate resources. In a resource-constrained environment, triage may lead to the acceptance of a lack of resources without challenging the problem of scarcity. A just system seeks to avoid triage by first implementing less drastic means of limiting and deferring the use of scarce resources. Before implementing any allocation system, appropriate steps may include cancellation of elective surgeries and altering patient to staff ratios. While the Guidelines incorporate specific clinical parameters on how to allocate ventilators to ensure that protocols are applied consistently throughout the State, there are drawbacks to a framework that is too rigid. Specifically, flexibility is necessary so that, if and when the Guidelines are needed, they are “current” with the latest data on the pandemic viral strain. As currently written, the Guidelines are based, when possible, on scientific data and previous emergency planning experiences, and reflect the most up to date and commonly accepted medical data. The Guidelines are intended to allow for flexibility; they should be updated and revised as there are advances in clinical knowledge or changes in societal norms. As a severe pandemic is unfolding and real-time data on the pandemic viral strain become 69 See Rubinson et al. Additionally, the Guidelines must not be used to summarily resolve the controversial question of ventilator use for severely and permanently impaired patients. Quality of life judgments must not serve as a substitute for ethically sound principles that are available for public scrutiny. The Guidelines must reflect our common duty to protect the rights of the disabled, even while potentially encompassing them in an allocation system. Health care providers and family members will be reluctant to withhold/withdraw ventilators from patients. Guidelines that rely heavily on withdrawal of ventilators generate great concern and controversy and may be set aside in an emergency. Further, the experience of withdrawing ventilation is traumatic for all concerned, including health care staff. Doctors and nurses forced to extubate patients, even to save other patients, may not recover full professional confidence until long after the pandemic is resolved. Finally, the withdrawal of ventilation 71 without patient consent raises significant liability issues; again, appropriate guidelines limit instances of tragic choices.

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The Pandemic Intervals Framework replaces the stages from the 2006 federal implementation plan for the National Strategy for Pandemic Infiuenza symptoms stiff neck cheap 400mg asacol. Actions • County and tribal health departments need to medicine rheumatoid arthritis discount asacol 400mg with visa maintain active participation in their respective Arizona Regional Public Health Preparedness Coordinating Committee treatment 2014 order 800 mg asacol mastercard. Vaccine and Antiviral Delivery and Administration Vaccines and antivirals are public health and medical tools to medicine 2016 buy asacol on line amex prevent and respond to infiuenza outbreaks. Their effectiveness during any given outbreak is not certain, especially during a pandemic due to a novel strain. While it is important for local plans to include the use of these tools as potential interventions, they should not be the only focus of an infiuenza pandemic response plan. Vaccines are to be used as a preventative measure, while antivirals will primarily be used as a treatment by health care providers. Community Disease Control Community Disease Control measures are those measures that are taken to limit or slow the spread of illness in a community. These measures will be best enacted at the local level, as they may only be necessary or effective in certain communities. Quarantine of contacts should be implemented only when there is a high probability that the ill patient is infected with a novel infiuenza strain that may be transmitted to others • Monitor contacts who are quarantined at least once a day—by phone or in person—to assess symptoms and address any needs • Note: As disease progresses throughout the community, use of quarantine may become less valuable outside of closed settings. These measures may include: ° Promotion of community-wide infection control measures. Measures used to address travel- related risks include many of the community disease control measures found in Supplement 8. During later pandemic phases, communication efforts will focus on coordinated health messaging to support public health interventions designed to limit infiuenza-associated morbidity and mortality. Use these reports to determine priorities among community outreach and education efforts, and to prepare for updates to media organizations in coordination with federal partners. Workforce Support – Psychosocial Needs All response agencies, including county and tribal health departments need to ensure that their response personnel reside in the safest and healthiest environment possible by addressing the psychological and social (“psychosocial”) needs of these employees (see Supplement 11). Such information will: • Educate and inform employees about emotional responses they might experience or observe in their colleagues and families (including children) during an infiuenza pandemic, and techniques for coping with these emotions. Information Management For pandemic planning and response public health information management focuses on technology systems that support response related interventions and resource tracking. Supplement 12 lists and describes all the statewide information management systems that will be used during a pandemic. County and tribal health departments should continue to participate in the development, testing, deployment, and use of these systems to ensure their overall effectiveness. This document covers the readiness and response plan for novel acute respiratory infections with pandemic potential. A pandemic is an epidemic of an infectious disease that has spread through human populations across geographical regions globally. Pandemics occur when the general population has no or little immunity against an emerging or re-emerging pathogen. Over the centuries, infectious diseases with different modes of transmission have resulted in pandemics, including influenza (respiratory spread), cholera (water- and food-borne) and bubonic plague (vector-borne). This document focuses on the national response framework against acute respiratory infections with pandemic potential. Influenza has been a major acute respiratory infection of interest as it caused four th pandemics since the turn of the 20 century. Previous influenza pandemics have shown no predictable periodicity or pattern and all differed with respect to antigenic subtype, epidemiology and disease severity. They can be more or less severe than preceding seasonal epidemics – while the 1918 H1N1 pandemic was associated with high mortality, the 2009 H1N1 pandemic was relatively mild. Both the ability of respiratory pathogens to spread (transmissibility) and the ability to cause serious illness (virulence) determine the extent of the outbreak and its resulting public health impact. However, the factors that 1 An epidemic occurs when new cases of a certain disease, in a given human population, and during a given period, substantially exceed what is expected based on recent experience. Reassortment events in swine remain a significant source of pandemic potential influenza viruses. Mammalian- adapted virus strains in other animal species, along with avian influenza virus strains that have shown the potential to infect humans, are also a potential threat. The laboratory syntheses of H5N1 influenza strains that can transmit efficiently among humans show their pandemic potential. Similarly, coronaviruses undergo genetic mutations and recombination at a rate similar to that of influenza viruses. Due to the extensive genetic diversity of these viruses, infections that result from coronaviruses can be difficult to predict and manage. Currently, the primary risk factor for human infection for avian influenza and novel coronaviruses appears to be direct or indirect exposure to contaminated environmental sources, with some human spread among close contacts. For efficient human-to-human transmission to occur, these pathogens must undergo further genetic changes and adaptation. Given the unpredictability of the respiratory pathogens, pandemics will likely occur again. Modeling studies notwithstanding, predictions of how particular disease strains will evolve remain highly speculative. Continued surveillance and monitoring of the global developments in the evolution of acute respiratory infections as well as pandemic preparedness and planning will serve to prepare us against the emergence of the next pandemic. Symptoms of different acute respiratory infections may vary depending on the pathogen. General symptoms may include constitutional symptoms such as fever, myalgia (muscle pains), headache, malaise (body discomfort), and respiratory symptoms such as cough, sore throat, and rhinitis (nasal inflammation). Certain populations such as the young, and elderly and those with underlying medical conditions may be at risk of developing a more severe illness including pneumonia. For example in influenza cases, uncomplicated illness is characterised by the abrupt onset of symptoms. Among children with influenza illness, otitis media (middle ear infection), nausea, and vomiting are also commonly reported. Influenza illness typically resolves after a few days for most patients, although cough and malaise can persist for more than 2 weeks. It is often difficult to identify a specific pathogen based on clinical symptoms alone because there is a wide range of pathogens that cause similar symptoms including, but not limited to, Mycoplasma pneumoniae, adenovirus, respiratory syncytial virus, rhinovirus, parainfluenza viruses, and Legionella spp. Laboratory tests are required to conclusively identify these pathogens, although in a pandemic where the majority of cases are caused by the pandemic pathogen, it is possible to intervene based on clinical symptoms alone. The sensitivity and specificity of any test may vary by the laboratory that performs the test, the type of test used, and the type of specimen tested. Among respiratory specimens for viral isolation or rapid detection of influenza, nasopharyngeal specimens are typically more effective than throat swab specimens. As with any diagnostic test, results should be evaluated in the context of other clinical information available to health-care providers. For example, rapid tests to detect influenza viruses within 30 minutes are widely available. These rapid tests differ in the types of influenza viruses they detect and whether they can distinguish between influenza types. The proportion of severe infections and mortality from respiratory infections varies widely, depending on risk factors such as comorbid conditions, age and immune status. It is therefore important to understand the virulence patterns of the disease in question. Influenza- related hospitalisation and deaths often result from pneumonia as well as from exacerbations of cardiopulmonary conditions and other chronic diseases. However, in an influenza pandemic, the mortality rates among the different population groups could be vastly different from that in seasonal influenza cases. We assume that the epidemiological features of a future acute respiratory infection pandemic will be consistent with previous known human epidemics and pandemics. However, these features should not be interpreted as being definitive of a novel pandemic pathogen. In the event of a pandemic, active and enhanced surveillance will be required in the early stages of the outbreak to determine the true nature of the pandemic pathogen. The incubation period will vary depending on the pathogen, and will have to be determined through surveillance.

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Clinical Strengths and Limitations of the Westmead Program A simple procedure Of all the treatments discussed symptoms ulcerative colitis purchase asacol, this is the simplest medications related to the lymphatic system generic asacol 400mg free shipping. So much so medicine 75 yellow buy discount asacol 800mg line, in fact medicine lodge ks generic 800mg asacol overnight delivery, that as soon as the parent and child learn to do the procedure, clinic visits begin to occur fortnightly. It may be useable for immediate early intervention Rhythmic stimulation is quite a simple procedure, so it may be more useable with younger children than is the case for the Lidcombe Program. Treatment credibility and expectancy There is a strong theoretical basis to the Westmead Program, not in the sense of stuttering causality, but in terms of the mechanism that might explain it. Apart from the fact that syllable-timed speech seems to be the oldest stuttering treatment method on record, the P&A Model described during Lecture Three provides a credible explanation for how it might work; syllable-timed speech removes the stress contrasts that trigger stuttering moments. A repetitive and drill-like procedure this aspect of the treatment could prove to be troublesome as it develops with further clinical trials. Even though parents rapidly learn to do the treatment with their children, it may prove to be quite wearing for them to sustain for long periods in order to obtain durable stuttering control. Summary the pre-school years are a time when stuttering is at its most tractable and when parents have optimal access to their children during daily life. Therefore early stuttering intervention is a desirable clinical option, either within-clinic or telepractice treatment. There are three treatment types for pre-school children for which there is clinical trial evidence: the Lidcombe Program, treatments based on Multifactorial Models, and the Westmead Program. The three treatments differ in clinical process and each has distinctive strengths and limitations. Practice sessions and Treatment during practice sessions used for too long into treatment. Low rate of verbal Verbal contingencies given infrequently during 8% contingencies practice sessions and conversations. Child has other speech or Clinician concurrently many 8% language problems treatment goals for different disorders. Stage 2 Entry to Stage 2 without attaining treatment criteria 5% Stopping verbal contingencies during Stage 2. Child unaware of stuttering Clinicians uncertain about whether to make child 2% aware of stuttering before treatment. Problematic parent-child Parent focused negatively on stuttering rather than 1% relationship constructive treatment. On watching a discipline shoot itself in the foot: Some observations on current trends in stuttering treatment research. Availability, access, and quality of care: Inequities in rural speech pathology services for children and a model for redress. A technique of social reinforcement for the study of child behavior: Behavior avoiding reinforcement withdrawal. Effectiveness of the Lidcombe Program for early stuttering in Australian community clinics. Clinical practice guideline: the pathogenesis, assessment and treatment of speech fluency disorders. Harrison (Eds), the Lidcombe Program of early stuttering intervention: A clinician’s guide (pp. Rhythmic speech training with preschool stuttering children: An experimental study. Treating stuttering in a preschool child with syllable timed speech: A case report. For that 1 format, the first Phase I non-randomised clinical trial with Australian children was published in 1990. One report involved 3–7 years 6 follow-up up of the children treated in that trial. The latter treatment arm involved a “rolling group” model, where a new family entered the group each time a family left the group. Fifty-four children were randomised, and clinical outcomes for the standard and group treatment are were consistent with outcomes from other clinical trials. However, the children in the group arm required around half the number of clinical hours than the children in the standard arm. Therefore the group Lidcombe Program treatment model was clinically efficient, although the treating clinicians in the trial “found group treatment to be more taxing but 9 clinically gratifying” (p. The design is known as a parallel, open plan, non-inferiority randomized controlled trial. Results showed no reason to believe that the webcam Lidcombe Program was less efficacious in terms of stuttering severity outcomes, or cost, than the clinic presentation. In fact, the webcam arm of the trial had 17% shorter treatment consultations than the clinic arm. There was no reason to believe that parents and children in either arm of the trial had a different relationship with the treating clinicians. It could turn out that this treatment method will be suitable for the majority of families. On the other hand, that may not be so and the final place for telepractice Lidcombe Program intervention may be as part of a stepped care public health approach to early stuttering. It provides the simplest and most cost efficient method of health care that is efficacious. It is self-correcting so that clients progressively escalate to more resource intensive, and more costly, models of health care if they are shown to need it. So, if families do not respond to telepractice early stuttering intervention, they might then go to a clinic each week. Or an intervening step might be that telepractice Lidcombe Program intervention is supplemented by occasional clinic visits. Work has begun to develop a standalone Internet Lidcombe Program treatment 17 that does not require a clinician, suggesting the possibility of such treatment as the first intervention in stepped care. The stepped care intervention model has been shown efficacious with management of 18,19,20,21,22 several disorders, but there seems to have been only one description of the stepped care 23 concept applied to stuttering. The Lidcombe Program in different cultures the treatment focuses on being a positive experience for children, and, as such, praise and acknowledgment for stutter-free speech is usually a clinically essential parent verbal contingency. Based on a study of Malaysian 24 parents and pre-schoolers, they concluded that “praise and acknowledgment of desirable behaviours appear to be used only infrequently in Malaysian cultures, and that when they occur, may not be 2 varied in expressions” (p. Four Malaysian pre-school children were studied, one of whom was treated in Mandarin and the others in English. The numbers of clinic visits to reach Stage 2 were 21, 31, and 57, which were longer than usual treatment times for the Lidcombe Program (to be overviewed shortly). The researchers reported that this seemed to have been caused by additional time required to teach the parents verbal contingencies, particularly praise for stutter-free speech. The researchers suggested approaches to the cultural issues about praise with the Lidcombe Program, such as variation of tonal and facial expression. Four of the children completed Stage 1 and based on beyond-clinic recordings were stuttering below 1. The authors reported that praising the children did not come naturally to the parents, and more time was spent training them to use verbal contingencies than is typical for Western parents. Additionally: Cultural factors were evident in the current study, such as the inability for women from traditional Bedouin families to drive to sessions on their own and relying on their husbands and other family members for transport. The children were assessed at pre- treatment, at entry to Stage 2 of the Lidcombe Program, and 9 and 12 months after the start of treatment. Four of the children completed Stage 1 in 14–22 clinic visits, which is consistent with clinical benchmarks (to be discussed shortly). The authors concluded that “young children with co-occurring stuttering and speech sound disorder may be treated concurrently using direct treatment approaches” (p. In-clinic Phase I trials the developers of this treatment have reported two Phase I clinical trials of it using in-clinic service 26,27 26 delivery, with a total of 12 children. The first trial recruited nine families, of whom three dropped 27 out, and the latter trial recruited six children who were retained in the trial. The results across the two non-randomised trials are presented in the figure for the 12 children. For some of the children in 27 the figure, follow-up data are for 6 months post-treatment, and for some the follow-up data are 12 26 months post-treatment.

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Materials encouraging their acquisition symptoms 9 weeks pregnancy buy asacol online now, I predict treatment yeast infection home purchase asacol 400 mg with visa, will be far more successful than materials encouraging their learning medicine quotes buy discount asacol 800mg line. The "learning node" dominates two subnodes medications used to treat fibromyalgia purchase asacol online now, one labeled "rules of thumb" and the other "structure of the target language". The former is learning that is actually meant as an aid to performance, the latter is optional learning, or language appreciation. It has been suggested (Krashen, Butler, Birnbaum, and Robertson, 1978) these rules are those that are (1) late acquired (or better, not yet acquired), and (2) "easy" to learn. A rule requiring a great deal of movement and permutation will not be easy to learn and apply. Another way in which a rule can be called "easy" is where the semantics of the rule are straightforward. Article use in English is simple in terms of the syntactic operations involved, but it is anything but "easy" in terms of the subtle semantic considerations required for its correct use. I am not prepared to supply a definite list of what rules can be taught; this is, I think, a worthy task for the Applied Linguistics profession to pursue. In syntax, the late, straightforward morphemes include the third person singular ending on regular verbs in the present tense, the possessive 114 marker /-s/, and the regular and irregular past endings. In writing, easily learned and useful rules include punctuation (but not all aspects: rules for capitalization and quotation marks are straightforward, but the rules for the comma and semi-colon may need to be acquired), and some spelling rules. The use of rules of thumb can increase accuracy in monitored performance to some extent. The "structure of the language" node is an optional section for those who have a genuine interest in the linguistics of the target language. I would personally be very interested in such information in any language I was acquiring, and most language science professionals, I assume, would also be interested. My impression is that most of our students would not be as eager for this kind of information, and the position outlined here implies that they need not be in order to gain a high level of proficiency in the target language. It is this class that can be devoted to a transformational analysis of the language being acquired, where the historical development of the language can be traced, etc. Students in such an optional section may need to be told that this information is not meant for use in actual language performance, unless one is a "super Monitor user". Conclusions My major point in this paper is to suggest that the second language 115 classroom might be a very good place for second language acquisition. The literature (Upshur, 1968; Carroll, 1967; Mason, 1971) contains some interesting evidence that the informal environment might be better than the classroom, but my re-analysis of this data indicates that what is really at issue is the amount of intake the acquirer can get (Chapter 3). In intake-rich informal environments, acquisition occurs, and in intake-poor classrooms, acquisition suffers. The acquisition-rich classroom might be extremely efficient, perhaps the most efficient solution for the adult second language acquirer. Intake is available via meaningful and communicative activities supplied by the teacher; this is the most direct way the classroom can promote language acquisition. As we have seen, there are other ways in which the classroom can encourage acquisition: in second language situations, it can aid in the development of the foreign student peer group, which is quite possibly an important intermediate source of intake. What is considered the most essential component of language instruction, explicit information about the language, and mechanical drill, may be the least important contributions the second language classroom makes. Although I can certainly study grammar on my own, I would elect to attend a second language class if I were again abroad for some period of time in a country where I did not know the language; my intention would be to gain intake, from the teacher, the classroom exercises, and from my fellow students. The subjects in the "Good Language Learner" study (Naimon, Frohlich, Stern, and Todesco, 1978) (the 34 case histories in the first section) combined "grammar" study and "immersion" as their preferred approach to second language acquisition. Several "good language learners" had grammar- type courses in the target language in school: ". This evidence is consistent with the generalization that the chief value of second language classes is their ability to provide the acquirer with appropriate intake, a conclusion that language teachers, through practice and experience, have come up with, and one which "theory", in this case "theory of language acquisition", also supports. Notes 1 Especially important are routines that enable acquirers to "manage" conversations with speakers who are more competent than they are in the language, routines that allow acquirers to get speakers to slow down, interrupt when necessary, change the subject, get help with vocabulary, etc. This occurs when a second language acquirer has learned a rule before actually acquiring it, and then subsequently does succeed in acquiring the rule. They have acquired equal amounts of English and are exposed to identical input/intake. Let us also assume that there does indeed exist an "average" order of acquisition for grammatical items, as claimed in Chapter 4. M Items to be acquired U 1 2 3 Time 1 4 5. Also, acquisition is not "all or none" as Brown (1973), Hakuta (1974), and Rosansky (1976) show; acquisition is not sudden and "acquisition curves" are not even necessarily linear. M, being a conscious learner, has no problem gaining 117 an explicit mental representation of 28, and begins to apply his conscious rule at time 1. He is thus able to supply rule 28 when the conditions for Monitor use are met: time and focus on form, and his performance on rule 28 is therefore variable. U ignored the formal presentation of 28 in class and does not supply it at all until time 2. At time 2, both M and U acquire 28, and use it consistently and appropriately in performance from time 2 on. Rather, 28 was acquired by both M and U through understanding intake, where the focus was on meaning and not form. In a sense, M was "faking" 28 until his acquisition caught up, or until he arrived at rule 28 "naturally". Some performers will not make it to 28 at all; they will "fossilize" (Selinker, 1972) earlier, due to failure to obtain enough intake, or a failure to utilize intake for acquisition due to an overactive affective filter. Positing a natural order and the existence of language acquisition in the adult allows us to explain the failure of conscious rules to always become automatic competence, and also explains cases like the above, where it appears that conscious rule was responsible for acquisition just because it "came first". Such responses indicated to me that the students had already acquired the structure I was attempting to teach, but had not learned it until my lesson. Students are often very happy to get this knowledge and feel they have really learned something. The only benefit I can see that such teaching may give, aside from the "language appreciation" function, is that an occasional overuser may be brought to understand that subconscious language acquisition is indeed a reality, and that he or she has a great deal of acquired competence that is worthy of his or her trust. The Theoretical and Practical Relevance of Simple Codes in Second Language Acquisition One of the most interesting case histories in the second language acquisition literature deals with two young acquirers of English as a second language, one successful and one unsuccessful. Such simple input is fixed on the "here and now" and contains a "limited body of graded language data", according to Wagner-Gough and Hatch. Ricardo, the unsuccessful acquirer, was 13 years old when he was studied by Butterworth (1972), another student of Hatch, Despite the fact that Ricardo had been in the United States only a few months, he had to participate in discussions that were quite complex, involving topics displaced in time and space and often using advanced syntactical constructions. Wagner-Gough and Hatch suggest that it was this input difference, rather than the age difference between Paul and Ricardo, that was the fundamental reason for their differential success in acquiring English as a second language. I can think of at least three ways Ricardo could have been provided with simpler input in English. First, he could have been a member of a "pull-out" class in school, either in English as a second language or in one or more subject-matters. This segregation from native speakers of English, distasteful to some, would have at least encouraged a simpler "teacher-talk" from his instructors, as all students in the class would have been less than fully competent speakers of English. Second, we could have provided Ricardo with opportunities to meet native speakers of English (for one method, see Krashen, 1978e). As long as such a foreign student peer group had different first languages, this would have provided Ricardo with "interlanguage" input, another simpler code. This is, I believe, a question of immense theoretical and applied interest, as fundamental as any in our field. Before discussing possible approaches to answering this question, some brief definitions are in order. We will focus on three sorts of simple codes that second language acquirers are apt to come into 120 contact with. It is, of course, fairly will described in the literature, but not dealt with as input. As documented by Hatch, Shapira, and Wagner-Gough (1978), this may happen after prolonged contact with second language speakers. The sort of foreigner-talk that is relevant to our discussion is the simplified input native speakers may give to less than fully competent speakers of their language in communicative situations. It may range from the sort of foreigner-talk described by Ferguson (1975), aimed at very low-level speakers and characterized by pidginization-type grammatical changes, to very mild alterations in speech. Whether these codes help the acquirer or not is an empirical question, and it is the purpose of this paper to suggest two possible approaches to investigating this issue.

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