H Learning and Brain Compatibility Creating a Learning Plan

Learning is not by accident… Brain Compatibility Principles All learning uses our senses 2.The Search for Meaning is Innate 3. Learning is Developmental 4. The Brain/Mind is Social 5. The Search for Meaning Occurs Through patterning 6. Emotions are critical to patterning

Brain Compatibility Principles The Brain/Mind Processes Parts/Wholes Simultaneously 8. Learning Involves Focused Attention and Peripheral Perception 9. Learning Involves Conscious and Unconscious Processes 7. The Brain/Mind Processes Parts/Wholes Simultaneously 8. Learning Involves Focused Attention and Peripheral Perception 9. Learning Involves Conscious and Unconscious Processes

Brain Compatibility Principles Spatial and Rote Memory 11.Complex Learning is Enhanced by Challenge and Inhibited by Threat 12. Each Brain is Uniquely Organized Ciaine and Caine J (1999) Mind/Brain Learning Principles 10. Spatial and Rote Memory 11.Complex Learning is Enhanced by Challenge and Inhibited by Threat 12. Each Brain is Uniquely Organized Ciaine and Caine J (1999) Mind/Brain Learning Principles

1. All Learning is Physiological: Learning uses ALL of Our Senses Learning is brain dependent so the most effective training engages the entire brain and uses: Sight- Use pictures, diagrams, and color Sound- Will music assist that patient who is depressed? Smell- Will a pleasant fragrance bring a smile and a story? Touch- Will the feel of a fabric evoke a memory? Taste- Is the patient enjoying the taste of his meals? The brain is a complex adaptive system… Learning is brain dependent so the most effective training engages the entire brain and uses: Sight- Use pictures, diagrams, and color Sound- Will music assist that patient who is depressed? Smell- Will a pleasant fragrance bring a smile and a story? Touch- Will the feel of a fabric evoke a memory? Taste- Is the patient enjoying the taste of his meals? The brain is a complex adaptive system…

Using sight…

Such a busy spider But what if I only saw my car?

Using Sight… What is your vision capability? When was your last eye appointment? What font is used with teaching materials? 8 font 10 font 12 font 14 font is thought to be more easily read 16 font How much clutter is on teaching tools? Is the message clear? Do you need to write out questions? Do you need larger clearer font?

SIGHT What about the learning space? Where is it? What does it look like? Is it a quiet learning space? What about the learning space? Where is it? What does it look like? Is it a quiet learning space?

CHARTS … GRAPHS… DIAGRAMS Simple charts can aid in learning Charts can make complex problems appear simpler Proceed from known to the unknown Learn about your patient’s learning style

Learning styles? Neuro-Linguistic programming 1. Visual Learners 2. Auditory Learners 3. Reading/Writing –Preference Learners 4. Kinesthetic /Tactile Learners

What is your preference? Visual Learners think in Pictures and have a preference for seeing (Have pictures, diagrams, get those handouts) Where are those colored markers? Auditory Learners learn through listening (Vivid terms used in lectures and discussions) A visual learner likes music in the background….go figure! Tactile/Kinesthetic Learners prefer to learn via experience (moving, touching, doing) Adults and children like to return demonstrate. Are we not all a little bit of each with a stronger tendency of one style of learning?

Sound Vivaldi or Mozart or ZZ Top or Bon Jovi or Lady GaGa…is the patient accustomed to learning with music? How do you learn? Do you like a din of music in the background? Is it distracting? Can music create a specific environment within a busy home? Can music aid in calming during a 3 hour IV or an uncomfortable process Vivaldi or Mozart or ZZ Top or Bon Jovi or Lady GaGa…is the patient accustomed to learning with music? How do you learn? Do you like a din of music in the background? Is it distracting? Can music create a specific environment within a busy home? Can music aid in calming during a 3 hour IV or an uncomfortable process

SMELL Learn what fragrances are appealing to you when learning… what does this mean? Would it have meaning to the patient/client….. Do you like fresh herbs, vegetables, baked bread? Why?… Learn what fragrances are appealing to you when learning… what does this mean? Would it have meaning to the patient/client….. Do you like fresh herbs, vegetables, baked bread? Why?…

TOUCH For the sensory deprived, swatches of various fabrics can be a pleasant source of discussion and stimulation

TASTE…

Sensory Percentages… What percentage of sensory information comes through each sense? Sight____ Hearing______ Smell________ Touch________ Taste________ What do you think? What percentage of sensory information comes through each sense? Sight____ Hearing______ Smell________ Touch________ Taste________ What do you think?

Importance of using all senses Sight 83% (so, why do we talk so much?) Hearing 11% Smell 3.5% Touch 1.5% Taste 1% Think about it: here in California, standing on a beautiful mountain (in Big Bear) on a clear sunny day we could see about miles, hear a mile away, smell about yards (if the wind is low), touch at arm’s length and taste what lands on our tongue. So, powerful mixed medium material is important…

2. The Search for Meaning is Innate There is a need to make sense of things. Adults learn better with a perceived need. Why are we creating a care plan or learning plan? All learners have the capacity to comprehend more effectively when their interests, purposes, and ideas are engaged. The teaching and learning must be specific, clearly express a purpose; an objective; information that identifies ‘if one does this then, a specific outcome can occur’. What tools can the clinician use to make learning meaningful? Do you use bright handouts and connect the problem/ opportunity/new event with the planned care for the specific desired result. Adults appreciate clarity. There is a need to make sense of things. Adults learn better with a perceived need. Why are we creating a care plan or learning plan? All learners have the capacity to comprehend more effectively when their interests, purposes, and ideas are engaged. The teaching and learning must be specific, clearly express a purpose; an objective; information that identifies ‘if one does this then, a specific outcome can occur’. What tools can the clinician use to make learning meaningful? Do you use bright handouts and connect the problem/ opportunity/new event with the planned care for the specific desired result. Adults appreciate clarity.

Search for Meaning…. Two important principles for providing patient information are simplicity and reinforcement. How do you learn? “Simplicity means delivering messages so the patient can readily understand.” This concept means assess first, as to the patient’s knowledge level on the subject. Move from the simpler to the complex

3. Learning is Developmental One research discovery is that the brain makes sense of new information by connecting information to something it already knows. Neurobiologist Edelman states the brain is like a jungle or a rain forest, rather messy and disorganized with a primary function: survival The brain is made up of numerous interconnecting systems. Each system functions individually but, contributes information that allows the brain to survive

Learning is Developmental All systems in the brain have the capacity to survive and thrive. “The brain supports the neural systems that are stimulated by their environments and frequently used.”

Neural Pruning When a neural system weakens, cells within it are redirected. Example, a native language no longer used will be replaced by a new language. When an infant is born s(he) is born with 100,000,000,000 brain neurons and twice the connections as an adult brain. By teen years, neurons are being pruned at a rate of 10,000 per second. Only those reinforced through experience, through action, through learning will survive!!!

Linked to Content…mmm You and your patient will be bombarded with new terminology new diseases, old diseases with new problems and treatments, Patient/client co-morbidities, Pharmacology ( Seniors now average10-15 medications) and you will be teaching others all about the above and their new i.e wound and how to care for it……How to remember…It can become overwhelming if you do not take steps! We need to listen and cultivate patient study habits that are brain compatible and individualized You and your patient will be bombarded with new terminology new diseases, old diseases with new problems and treatments, Patient/client co-morbidities, Pharmacology ( Seniors now average10-15 medications) and you will be teaching others all about the above and their new i.e wound and how to care for it……How to remember…It can become overwhelming if you do not take steps! We need to listen and cultivate patient study habits that are brain compatible and individualized

You will be sharing a new language… It is called Medical Terminology It may be new to the patient….

Linking information to familiar topics, stories, learning experiences, prior knowledge We know, through research, that we learn when we build upon prior learning osteo and bone….itis and inflammation We know, through research, that we must link the information in our mind to prior learning or experiences and use the information so the learning solidifies We know, through research, that pressure can be a deterrent or a motivator to learning. It all depends … We know, through research, that we learn when we build upon prior learning osteo and bone….itis and inflammation We know, through research, that we must link the information in our mind to prior learning or experiences and use the information so the learning solidifies We know, through research, that pressure can be a deterrent or a motivator to learning. It all depends …

Learning under Pressure How would you do? Let’s apply some pressure. You have 30 seconds to memorize …then, write down all 17 digits seen below, in proper sequence…with NO ERRORS and no looking: How would you do? Let’s apply some pressure. You have 30 seconds to memorize …then, write down all 17 digits seen below, in proper sequence…with NO ERRORS and no looking:

How would you feel… You have answers but will you always?

Link to familiar topics Ok, the pressure was on, let’s use some of our senses and let’s have some fun: 3 pigs met 1 Snow White and 7 small people on Highway 40 on 7/21 at 12:00 midnight. They decided to stop for dinner and had 11 salads and 22 bottles of water and left a tip of 9 dollars Ok, the pressure was on, let’s use some of our senses and let’s have some fun: 3 pigs met 1 Snow White and 7 small people on Highway 40 on 7/21 at 12:00 midnight. They decided to stop for dinner and had 11 salads and 22 bottles of water and left a tip of 9 dollars

Numbers numbers numbers numbers numbers What if we broke the numbers into smaller sections? Because we had a story: With no story: How about… So, we need to take the time…assess anxiety levels, assess perception to learning, use some stories and some metaphors that relate to his/her background

Building on prior learning New information builds upon what is already known. This cumulative process is accompanied by physiological changes. How we learn as a child or as a teen is different that how we learn as a young and older adult. The mental alteration is modified by new experiences and so the cycle continues…

Create meaning… We must create meaning. How do we do that? Have you reviewed the subjects to be discussed in each term? Have you created a schedule of reading and study for each week? Think of something you learned that is hardwired in your brain. What made some of these learning experiences memorable? Anyone remember their first grade or pre school teacher? Why? We want what we learn to become hardwired…to remain within us. We must create meaning. How do we do that? Have you reviewed the subjects to be discussed in each term? Have you created a schedule of reading and study for each week? Think of something you learned that is hardwired in your brain. What made some of these learning experiences memorable? Anyone remember their first grade or pre school teacher? Why? We want what we learn to become hardwired…to remain within us.

4. The Brain/Mind is Social “Contact Urge”….That is what cognitive scientists Gopnik, Meltzkoff, and Kuhl call it. Learning is more enhanced when there is interactivity. Learners of all ages comprehend more effectively when their needs for social interactions and relationships are met. People learn by doing… Quilting Bees, Study Groups, Paint Parties….Family events… Support groups like…… “Contact Urge”….That is what cognitive scientists Gopnik, Meltzkoff, and Kuhl call it. Learning is more enhanced when there is interactivity. Learners of all ages comprehend more effectively when their needs for social interactions and relationships are met. People learn by doing… Quilting Bees, Study Groups, Paint Parties….Family events… Support groups like……

Social and Attitude Attitude significantly factors in the effectiveness of study habits in all students. Strategies that are helpful to make study more enjoyable include: Createa positive attitude by actively participating in the learning. Keep in mind why you chose to become a LVN. Interact with the material by asking questions, writing comments in the margins of textbooks or notes Find ways to make the material more relevant to your situation as much as possible Reward yourself after each study segment with breaks, music, walks, low calorie food. Attitude significantly factors in the effectiveness of study habits in all students. Strategies that are helpful to make study more enjoyable include: Createa positive attitude by actively participating in the learning. Keep in mind why you chose to become a LVN. Interact with the material by asking questions, writing comments in the margins of textbooks or notes Find ways to make the material more relevant to your situation as much as possible Reward yourself after each study segment with breaks, music, walks, low calorie food.

5. The Search for Meaning Occurs through Patterning Patterning refers to meaningful organization and categorization of information People make sense of experience by their mind’s seeking patterns and relationships The brain is designed to perceive and generate patterns and struggles to reject meaningless patterns imposed on it. We learn via categories, types, frames, schemata, conventions, design, outlines, flowcharts….. Patterning refers to meaningful organization and categorization of information People make sense of experience by their mind’s seeking patterns and relationships The brain is designed to perceive and generate patterns and struggles to reject meaningless patterns imposed on it. We learn via categories, types, frames, schemata, conventions, design, outlines, flowcharts…..

Constructing a Plan Find patterns that connect the learning.. Identify what you know about the subject and related subjects. What are your experiences with the disease process? What learning must you accomplish over the next ___weeks. Construct your patient’s learning plan together. Have objectives. Discuss objectives. Do they make sense to the patient?. List your constructs or key elements that are unclear. Schedule a time for discussion with your patient. Talk about the plan of care. Seek suggestions. Is your planned schedule and goals realistic for the next ___weeks to accomplish these goals. Find patterns that connect the learning.. Identify what you know about the subject and related subjects. What are your experiences with the disease process? What learning must you accomplish over the next ___weeks. Construct your patient’s learning plan together. Have objectives. Discuss objectives. Do they make sense to the patient?. List your constructs or key elements that are unclear. Schedule a time for discussion with your patient. Talk about the plan of care. Seek suggestions. Is your planned schedule and goals realistic for the next ___weeks to accomplish these goals.

Add to your Plan Does your Plan include? Maintaining a positive attitude Include active participation Return demonstrations Taking notes HOW? Creating Study/Patient Flash cards! YES! Reward your patient with positive reinforcement Does your Plan include? Maintaining a positive attitude Include active participation Return demonstrations Taking notes HOW? Creating Study/Patient Flash cards! YES! Reward your patient with positive reinforcement

Study Skills SPECIFIC STUDY SKILLS- These skills have been identified by counselors as critical for all successful students and they are areas in which many students are deficient. Note-taking (encourage your patient to take notes.) Listening (ask for input and comment) Reading or voice guidance Writing and markers Importance of prep prior to the visit

Constructing Patterns of Learning A pattern is “an ordered configuration of relationships”; a combination of things that seem to fit together. So, when we try to figure out the meaning of something new, we search for patterns that make sense to us. We organize information and seek commonalities. Once we organize a new concept and fit it into our lives, we begin to create a mental model Once we get a pattern, it sticks. We then get the concept. You know, that “EUREKA” feeling! A pattern is “an ordered configuration of relationships”; a combination of things that seem to fit together. So, when we try to figure out the meaning of something new, we search for patterns that make sense to us. We organize information and seek commonalities. Once we organize a new concept and fit it into our lives, we begin to create a mental model Once we get a pattern, it sticks. We then get the concept. You know, that “EUREKA” feeling!

Patterns Neural network verify if sensory stimuli forms a familiar pattern. If they do…a match occurs and the brain determines that the new stimuli are familiar and have meaning. If there is no match, the brain may attend to new unreinforced, unmatched information for a short period of time and then it will not be processed further. One part of our job is to “make matches” Neural network verify if sensory stimuli forms a familiar pattern. If they do…a match occurs and the brain determines that the new stimuli are familiar and have meaning. If there is no match, the brain may attend to new unreinforced, unmatched information for a short period of time and then it will not be processed further. One part of our job is to “make matches”

Constructing Patterns: Are you a note taker? Look around….How many of you have jotted down notes in language and doodles that has meaning to you? Is your patient afforded that opportunity? Is your patient a visual learner? Do you like markers and highlighters? Do they? Color…

Constructing Patterns in Learning Would your patient benefit from a journal to write about the learning experience? Would that empower her/him? Would they benefit from listing questions for you? Would they benefit from writing about how they feel? What do they want to accomplish? Having a notepad/journal can link one tangibly with the learning……

Graphic organizers can assist a patient to see ORDER: A flow chart shows the steps involved A cycle shows a repeating pattern of steps An episode pattern organizer shows cause and effect for a series of events A timeline sequences events Any of these can add clarity… Patterning is assisted by Graphic organizers

6. Emotions and Learning Artists and writers and many surgeons have known for years, what neuroscientists have now confirmed…emotions are involved in every thought, in every decision, and in every response.

Stress and Learning Stress is a heightened arousal to some stimulus; event, person, object. Over the past 30 years we have learned much about the topic. We know that the body creates the hormone cortisol in direct response to stressors. Chronic stress would cause long term high levels of cortisol in the body. The hippocampus, the section of the brain specifically associated with new learning, is also the area of the brain with high sensitivity to cortisol and is negatively affected by high effects of the hormone. Thus, negative stress impedes learning.

High Stress Learning Situations High stakes learning situations such as learning new meds or new treatments or IV infusion, are situations that produce stress. If stress is not mitigated, the ability to learn effectively can be placed in jeopardy.

Stress…minimize but do not eradicate Reduce harmful stress with a calm organized approach. Create a designated section of calm in the home, even if there is chaos surrounding you and the patient. Keep focused and refocused on the teaching/learning Remember, we also need positive stress for personal volition and motivation. Positive stress is actually required for learning but, negative stress is a distracter. Reduce harmful stress with a calm organized approach. Create a designated section of calm in the home, even if there is chaos surrounding you and the patient. Keep focused and refocused on the teaching/learning Remember, we also need positive stress for personal volition and motivation. Positive stress is actually required for learning but, negative stress is a distracter.

Emotions and Ligands Scientists have known that neurons are the cells in the brain that transmit signals for human function. Neuroscientists led by Candace Pert have now proven that chemicals, called neurotransmitters, carry signals across nerve synapses and between neurons and make mood and emotion possible. Those transmitters are a part of a class of chemicals called ligands which are found throughout the body, including the immune system

Emotions Every emotion that a person feels is accompanied by a flow of ligands which is why metaphors frequently provide understanding: He lost his cool, He’s letting off steam, He’s hot under the collar…The emotion described?

and Cooler Emotions Sometimes we are not as emotionally involved…

Ask for Feedback Feedback can help to improve performance if phrased in a supportive manner. Frame comments positively as the brain does not have images for not… (conduct banana image) Be positive in asking questions or when teaching. …If you wear a new shirt and you receive several compliments on how that great that color looks on you….what is the likelihood that you will wear it in the future? Feedback can help to improve performance if phrased in a supportive manner. Frame comments positively as the brain does not have images for not… (conduct banana image) Be positive in asking questions or when teaching. …If you wear a new shirt and you receive several compliments on how that great that color looks on you….what is the likelihood that you will wear it in the future?

7. The Brain/Mind Processes parts and wholes simultaneously Making sense of a story or a new procedure requires both a big picture and the individual parts We can comprehend more effectively when specific facts are embedded in the “whole” process Chunk content with a purpose For the diabetic patient, link individual parts of diabetic teaching to the total goals for the episode and beyond the plan of care For new students/patients, link infection control to handwashing >to disease > to transfer to student/patient family

Parts and Wholes You, the clinician/educator, should be able to identify the purpose of the class/visit. What are the objectives and what should you anticipate for this particular class/visit and the classes/visits to follow. What are the objectives for the body system section and the term. How does this term fit within the entire program? The patient should know the expectations for each day/visit and each hospital stay or home health episode. What is expected of them as stated in their Plan of Care? You, the clinician/educator, should be able to identify the purpose of the class/visit. What are the objectives and what should you anticipate for this particular class/visit and the classes/visits to follow. What are the objectives for the body system section and the term. How does this term fit within the entire program? The patient should know the expectations for each day/visit and each hospital stay or home health episode. What is expected of them as stated in their Plan of Care?

How about a concept map? Creates Image Shows Endpoint Nice cup of tea Tea Leaves Hot Water Lovely Tea Pot More Cups- A Tea Party Relaxing

Every day millions of stimuli attack our senses …Do we perceive all of it? We are constantly immersed in a lake of stimuli and we select what we will attend to. Is that a good idea? Were you aware of the sensations of your clothes this morning when you put them on? Probably not. Before I alerted you, were you hearing every sound around you? If I can garner your attention…the other sounds will fade for a while…But I must keep assisting to refocus your attention and I only have 18 seconds each time to GRAB YOU. How many seconds does the clinician have with the patient, to teach? How many minutes can I keep YOUR attention? Every day millions of stimuli attack our senses …Do we perceive all of it? We are constantly immersed in a lake of stimuli and we select what we will attend to. Is that a good idea? Were you aware of the sensations of your clothes this morning when you put them on? Probably not. Before I alerted you, were you hearing every sound around you? If I can garner your attention…the other sounds will fade for a while…But I must keep assisting to refocus your attention and I only have 18 seconds each time to GRAB YOU. How many seconds does the clinician have with the patient, to teach? How many minutes can I keep YOUR attention? 8. Learning involves both focused attention and peripheral perception

I want YOU to enjoy learning…

Focus Focus Focus If we selectively perceive environmental stimuli, is that a good thing? Yes, if we could not eliminate the irrelevant, we would not be able to run very very fast, away from that rabid dog chasing us, flying by Mrs Jones red tulips and ignoring that adorable humming bird and those pretty blue flowers. We are hardwired with an automatic ability to filter out, what we perceive to be, the less relevant. Isn’t that a good thing? So, how does this impact patient care? If we selectively perceive environmental stimuli, is that a good thing? Yes, if we could not eliminate the irrelevant, we would not be able to run very very fast, away from that rabid dog chasing us, flying by Mrs Jones red tulips and ignoring that adorable humming bird and those pretty blue flowers. We are hardwired with an automatic ability to filter out, what we perceive to be, the less relevant. Isn’t that a good thing? So, how does this impact patient care?

Effective learning is layered, appealing to various levels of consciousness. A one time discussion to a new diabetic will not be enough. Giving handouts will not be enough. Reinforcement after reflection will be necessary. Some learning requires an individual to consciously attend to a situation Some learning requires unconscious incubation…..reflective learning Patients need time to think about their learning.? Effective learning is layered, appealing to various levels of consciousness. A one time discussion to a new diabetic will not be enough. Giving handouts will not be enough. Reinforcement after reflection will be necessary. Some learning requires an individual to consciously attend to a situation Some learning requires unconscious incubation…..reflective learning Patients need time to think about their learning.? 9. Learning involves conscious and unconscious processes

10. Two memory systems: Spatial and Rote Learning requires an actual physical change in the electrical activity and neurons in the brain…in order to have long term memory Long term memory requires layered teaching Information delivered without reinforcement will, in all likelihood, be lost

We have at least two ways to organize memory: A spatial memory system and a rote learning system Spatial Memory System Engages multiple mental systems Patients comprehend more effectively when involved in learning that involves many ways to remember Engages multiple mental systems Patients comprehend more effectively when involved in learning that involves many ways to remember Rote Learning System A learning technique which avoids topic understanding, focusing instead on memorization Archived isolated facts and skills taught to comprehend text A learning technique which avoids topic understanding, focusing instead on memorization Archived isolated facts and skills taught to comprehend text

The brain and learning The brain calls upon associations to make sense of the world. Material memorized by rote is not transferable unless tied to an association/experience per researcher R. Sylvester Memories are contextual. Clinicians may need to draw out past experiences

Short Term Memory Information that we perceive enters short-term memory. If untreated, the information will be gone within seconds. Short term memory fills quickly, only 5-10 items at a time. To expand the load, combine the information into chunks…

Chunks of Information Remember when you recreated North, South, East, and West into your memory as NEWS….1 chunk Every Good Boy Does Fine..EGBDF

11. Complex learning is enhanced by challenge and inhibited by threat associated with helplessness and/or fatigue Neuroscientists, creative and stress theorists, and perceptual psychologists have demonstrated through research that effective mental and emotional functioning can be sabotaged by fears associated with helplessness.

Frightened negative emotion can hijack learning. The need for rest can sabotage learning Individuals need support, patience, empowerment and they need challenge. They need: A Learning Challenge with Support and a Guided Map To Expected Care Outcomes is Needed Keep focused on your/their goals! Complex Learning

12. Each Brain is Uniquely Organized Effective teaching must respect the individual…unique DNA and a unique brain Focus on that learning patient Share that learning …it requires change Engage those individualized talents

Adult Learning 1. Adult learners want to contribute to their learning Readiness 2. Adults want to be able to use the learning immediately Experience Autonomy Action 3. Adults learn best when they are interested in the subject, are respected, and can make their decisions. 4. Adults learn best when the learning content can integrate with some of their knowledge

Commit to Learning Learning Create an Active Learning Care Plan 1.Use charts, graphs, color 2.Use Journals 3. Use reflection notes 4. Be Engaged in your in learning plan development and update Linking to Patterns, encouraged interactivity, Mutual respect, clear understanding of visit objectives and endpoints Effective Guided Learning Experience Interests Create a Learning Environment Student Interests Learning Planning Learner Support Learning needs Link to Prior Learning Environment Learner Focus

Summary 1. All learning uses our senses 2.The Search for Meaning is Innate 3. Learning is Developmental 4. The Brain/Mind is Social 5. The Search for Meaning Occurs Through patterning 6. Emotions are critical to patterning

Summary 7. The Brain/Mind Processes Parts/Wholes Simultaneously 8. Learning Involves Focused Attention and Peripheral Perception 9. Learning Involves Conscious and Unconscious Processes

Summary 10. Spatial and Rote Memory 11.Complex Learning is Enhanced by Challenge and Inhibited by Threat 12. Each Brain is Uniquely Organized Ciaine rand Caine J (1999) Mind/Brain Learning Principles