Narcissism and Fantasy 499

SINGER, J. L., & ANTROBUS, J . S. (1972). Daydreaming. imaginal processes, and personality: A normative study. In P. Sheehan (Ed.), The function and nature of imagery @p. 175-202). New York: Academic Press.

STONE, A. A., & NEALE, J. M. (1984). New measure of daily coping: Development and preliminary results. Journal of Personality and Social Psychology, 46, 892-906.

TARTAKOFF, H. H. (1966). The normal personality in our culture and the Nobel Prize Complex. In R. M. Lowenstein, L. M. Schurm, & A. J. Solnit (Eds.), Psychoanalysis: A generalpsychology, essays in honor of Heinz Hartmann (pp. 222-252). New York: International Universities Press.

VOLKAN, V. (1979). The ‘‘glass bubble” of the narcissistic patient. In J. Leboit & A. Capponi (Eds.), Ad- vances in psychotherapy of the borderline patient. New York: Jason Aronson.

WATSON, P. J., GRISHAM, S. O., TROTTER, M. V., & BIDDERMAN, M. D. (1984). Narcissism and empathy: Validity evidence for the Narcissistic Personality Inventory. Journal of Personality Assessment, 48, 301-305.

ZELIN, M. L., BERNSTEIN, S. B., HEUN, C., JAMPEL, R M., MEYERSON, P . G., ADLER, G., BUIE, D. H., & RIZZIJTO, A. M. (1983). The Sustaining Fantasy Questionnaire: Measurement of sustaining functions of fantasies in psychiatric inpatients. Journal of Personality Assessment, 47, 427-439.

DEPRESSION AND ENGAGEMENT IN PLEASANT AND UNPLEASANT ACTIVITIES IN NORMAL CHILDREN

MICHAEL WIERZBICKI AND MARILYN KAFF SAYLER

Washburn University

This study investigated Lewinsohn’s reinforcement model of depression by examining the relationship between depressive symptomatology and mood- related activities in normal children. Subjects were 138 children aged 8 to 14 years. Children and their parents rated the children’s depression and engagement in pleasant and unpleasant activities. It was found that children’s depression was correlated positively with increased engagement in unplea- sant activities. However, the predicted negative correlation between children’s depression and engagement in pleasant activities was supported only when children’s mood was assessed by parental report, and not by children’s self-report.

Childhood depression has become the focus of an increasing amount of investiga- tion. Kaslow and Rehm (1983) reviewed the recent literature on childhood depression and concluded that the manifestation of depression in children parallels that of depres- sion in adults, with some additional developmentally appropriate symptoms. DSM-111-R (American Psychiatric Association, 1987) concurs, indicating that the essential features of mood disorders in children are the same as in adults.

Because depression in children has been found to resemble depression in adults, recent research has begun to address whether theoretical models of depression, originally developed and tested within adult populations, might generalize to children.

One model of depression that has been examined extensively in adults is that of Lewinsohn (1974), which proposed that depression is caused by decreased positive rein- forcement. Thus, factors that limit reinforcement, such as social skills deficits or infre- quent engagement in pleasant activities, increase depression.

A portion of these data formed the basis of a master’s thesis by the second author conducted under the supervision of the first author and submitted in partial fulfillment of the requirements for the Master of Arts degree in Psychology at Washburn University. The authors would like to thank Laura Hubbs-Tait and Laura A. Stephenson, who served as thesis committee members.

A portion of these data was presented at the 1989 meeting of the Midwestern Psychological Association. Requests for reprints should be addressed to Michael Wierzbicki, Department of Psychology, Marquette

University, Milwaukee, WI 53233.

500 Journal of Clinical Psychology, July 1991, Vol. 47, No. 4

Lewinsohn and others have shown that depression is related to pleasant and unplea- sant activities in students (Lewinsohn & Libet, 1972; Rehm, 1978); community volunteers (Lewinsohn & Amenson, 1978; Lewinsohn, Mermelstein, Alexander, & MacPhillamy, 1985; MacPhillamy & Lewinsohn, 1974); and patients (Grosscup & Lewinsohn, 1980; Lewinsohn & Graf, 1973; Lewinsohn & Talkington, 1979).

Lewinsohn also has examined the relationship between adults’ depression and ac- tivities as a function of age. Lewinsohn and Graf (1973) found that more activities were correlated with daily mood for adults aged 30 to 49 years than for either older or younger adults. Lewinsohn and Talkington (1979) observed that younger adults tended to engage in slightly more unpleasant activities than older adults. Thus, although the relationship between depression and activities is robust across age, there may be differences across age groups that warrant further attention.

The research cited above is correlational and so does not prove that decreased rein- forcement causes depression. However, experimental studies have demonstrated that treatment that consists of or includes scheduling activities to increase reinforcement significantly alleviates clinical depression (e.g., Brown & Lewinsohn, 1984; Steinmetz, Lewinsohn, & Antonuccio, 1983; Turner, Ward, & Turner, 1979).

Lewinsohn also has examined the relationship between social skills and depression because his model suggests that individuals who earn low social reinforcement may be at risk for depression. Lewinsohn has demonstrated that depressed individuals differ from and are less socially skillful than nondepressed individuals in group interactions (Libet & Lewinsohn, 1973) and in self-reported assertive behavior (Sanchez & Lewin- sohn, 1980). Similarly, others have demonstrated that social skills are correlated with both concurrent and subsequent depression (e.g., Wierzbicki, 1984).

In addition to this correlational research, experimental studies have shown that treatment that consists of (or includes as one component) social skills training significantly alleviates clinical depression (Hersen, Bellack, & Himmelhoch, 1980; McLean & Hakstian, 1979).

Recent studies have examined the extent to which Lewinsohn’s model generalizes to children. In normal children, depression has been found to be related to social skills as rated by teachers, parents, self, peers, and others (e.g., Altmann & Gotlib, 1988; Fauber, Forehand, Long, Burke, & Faust, 1987; Jacobson, Lahey, & Strauss, 1983; Strauss, Forehand, Frame, & Smith, 1984; Wierzbicki & McCabe, 1988). Similar rela- tionships also have been found in inpatient children (e.g., Asarnow & Bates, 1988).

Another series of studies has examined the relationship between children’s depres- sion and activities. Neither Kaslow, Rehm, and Siege1 (1984) nor Wierzbicki and McCabe (1988) found a relationship between children’s depression and activity levels assessed by the Social Competence scales of the Child Behavior Checklist (CBCL; Achenbach, 1978). Wierzbicki and McCabe suggested that these CBCL scales, which measure in- volvement in activities, school relationships, and school performance, may not assess adequately the types of activities that are influential in producing depression. They sug- gested that future research should consider the relationship between children’s depres- sion and their engagement in pleasant and unpleasant activities.

Garber (1982) developed the Children’s Event Schedule (CES\, which includes 75 pleasant and 75 unpleasant childhood activities to be rated for both frequency and pleasantness. However, no information has appeared in the literature to date with respect to the development, reliability, and validity of the CES.

Carey, Kelly, Buss, and Scott (1986) developed the Adolescent Activities Checklist (AAC). The AAC consists of 100 pleasant and unpleasant activities that are rated for frequency and impact. Carey et al. reported that the AAC had high internal consistency and homogeneity. They also found a positive correlation in nonpatient adolescents be- tween self-reported depression and engagement in unpleasant activities.

Children and adolescents do not necessarily engage in the same activities, and so the AAC may not generalize from adolescents to children. There is a need for an empirically

Children 3 Depression and Activities 501

based activities checklist for use with children. Such a checklist will be useful in ex- amining the relationship between depression and activities in children and so testing the generalization to children of Lewinsohn’s reinforcement model of depression.

This study examined the association between depression and activities in normal children. Two hypotheses were tested: (1) There would be a positive correlation between children’s depression and engagement in unpleasant activities; and (2) there would be a negative correlation between children’s depression and engagement in pleasant activities.

METHOD

Subjects Subjects were 138 children aged 8 to 14 years (A4 age = 10.43 years), including 66

boys and 72 girls. Subjects were children of college students who volunteered to par- ticipate in research on children’s mood and activities. Information on children’s race and socioeconomic status was not gathered. However, students at this college are predominantly White (90%) and middle-class.

Measures Child questionnaire. The child questionnaire contained the Children’s Depression

Inventory (CDI; Kovacs, 1978), the Pleasant Activities Survey (PAS: Wierzbicki, 1986a), and the Unpleasant Activities Survey (UAS; Wierzbicki, 1986b). Children used these measures to rate their level of depressed mood and their engagement in pleasant and unpleasant activities during the previous 2 weeks.

The CDI contains 27 items, each of which concerns a symptom of depression that is rated on a 3-point scale for its presenceand severity. Kovacs (1980) has presented evidence that supports both the reliability and validity of the CDI.

The PAS and UAS consist of, respectively, 70 pleasant and 70 unpleasant activities that commonly are experienced by school-aged children. The frequency and the (un)pleasantness of each activity are rated on 3-point scales. The PAS and UAS each yield three scores: Frequency, (Un)Pleasantness, and Total (Un)Pleasantness (the cross- product of Frequency and [UnlPleasantness).

Internal consistency has been found to be high for the child forms of the UAS and PAS (Cronbach’s CY > .87 for all scales) (Wierzbicki & Sayler, 1989).

Parent questionnaire. Parents completed forms of the CDI, PAS, and UAS, rating their children’s level of depression and engagement in pleasant and unpleasant activities during the previous 2 weeks.

Parents used a parent form of the CDI to rate their children’s level of depression. Wierzbicki (1987) presented evidence for the reliability and validity of this parent form of the CDI for rating depression in nonclinical populations of children.

Parents rated their children’s engagement in activities on forms of the PAS and UAS. Parents rated both the frequency and (un)pleasantness of their children’s activities on 3-point scales.

Internal consistency has been found to be high for the parent forms of the UAS and PAS (Cronbach’s (11 > .87 for all scales) (Wierzbicki & Sayler, 1989).

Modest, but significant correlations have been found between the child and parent forms of the UAS and PAS for the Frequency, (Un)Pleasantness, and Total (Un)Pleasantness scales (Wierzbicki & Sayler, 1989)’ which supports the validity of the UAS and PAS.

Procedure

Children and their parents met in small groups with an investigator. Parents com- pleted a questionnaire independently. Children were read the instructions and then were assisted with the completion of a questionnaire.

502 Journal of Clinical Psychology, July 1991, Vol. 47, No. 4

Because of scheduling limitations, not all subjects completed all measures. All measures were administered to 44 children and their parents; the CDI and UAS alone were administered to 71 children and their parents; the CDI and PAS alone were ad- ministered to 23 children and their parents.

RESULTS

A two-way multivariate analysis of variance using Wilks’ lambda criterion deter- mined that neither Sex, F(2, 123) = 2.39, ns, Age, F(12, 246) = 1.72, ns, nor the in- teraction between Sex and Age, F(12,246) = 1.24, ns, was related significantly to depres- sion scores on the two forms of the CDI. Thus, both sexes and all ages were combined in the remaining analyses. Children’s self-report CDI scores had a mean of 8.23 (SD = 6.22) and ranged from 0 to 32. Parents’ ratings of children’s depression on the parent form of the CDI had a mean of 5.49 (SD = 5.42) and ranged from 0 to 30.

It had been predicted that children’s mood would be associated with their engage- ment in pleasant and unpleasant activities. This was tested by examining the correla- tions between the CDI and both the UAS and PAS, using both child and parent forms. Correlations between the CDI and both the UAS and PAS are presented in Table 1.

Children’s self-reported depression was correlated significantly and positively with their self-reported Frequency, Unpleasantness, and Total Unpleasantness scores on the UAS. In addition, children’s self-reported mood was correlated significantly and positively with parents’ ratings of the Unpleasantness and Total Unpleasantness of children’s unplea- sant activities.

Parents’ ratings of children’s depression were correlated significantly and positively with all but one subscale (Child UAS- Unpleasantness) of the child and parent forms of the UAS. Thus, the prediction that children’s depression level would be correlated positively with their engagement in unpleasant activities was supported. Although the correlations were of a modest magnitude, all were in the predicted direction, and almost all were statistically significantly greater than zero.

Children’s self-reported depression was not correlated significantly with any subscale of the child and parent forms of the PAS. However, parents’ ratings of children’s mood were correlated significantly and negatively with children’s ratings of the Pleasantness and Total Pleasantness of their pleasant activities and also with parents’ ratings of the Frequency and Total Pleasantness of children’s pleasant activities.

Table 1 Correlations between Children’s Mood and Engagement in Unpleasant and Pleasant Activities

UAS/PAS form

Child CDI Parent CDI

rCDl.UAS rCD1,PAS rCD1.UA.S rCDI.PAS ~

Child Frequency (Un)Pleasantness Total (Un)Pleasantness

Frequency (Un)Pleasantness Total (Un)Pleasantness

Parent

.40** - .04 .17* -.17

.16* - .18 .12 - .22*

.39** - .10 .23** - .21*

.15: - .04 .32** - .26*

.24** .05 .24** - .09

.29** .02 .38** - .23* ~~ ~

Note. - UAS = Unpleasant Activities Survey. PAS = Pleasant Activities Survey. CDI = Children’s Depres- sion Inventory. n = 115 for UAS correlations. n = 67 for PAS correlations.

* p < .05. * p < .01.

Children’s Depression and Activities 503

DISCUSSION

This study examined the relationship between normal children’s depression and engagement in pleasant and unpleasant activities.

The predicted positive correlation between depressed mood and unpleasant activities was supported by both children’s and parents’ ratings of children’s mood and behavior. This finding is consistent with results found in patient and nonpatient adults (Grosscup & Lewinsohn, 1980; Lewinsohn & Amenson, 1978) and in nonpatient adolescents (Carey et al., 1986). This lends further support to the extension to children of models of depres- sion originally developed and tested in adult populations.

However, the predicted negative correlation between children’s depression and engagement in pleasant activities was supported only when parents’ and not children’s ratings of children’s depression were employed. Children’s self-reported mood was not related to child or parent ratings of children’s pleasant activities.

Although this is not consistent with what has been reported in patient and nonpa- tient adults (e.g., Lewinsohn & Amenson, 1978; Rehm, 1978), it is consistent with what has been found in nonclinical children and adolescents. Carey et al. (1986) found that pleasant activities did not discriminate depressed from nondepressed adolescents. Swear- ington and Cohen (1985) found that depression in young adolescents was correlated significantly with negative life events, but was unrelated to positive life events. Similarly, Mullins, Siegel, and Hodges (1985) found that, in normal children, depression was cor- related significantly with negative life events, but was unrelated to positive life events.

These studies suggest that pleasant activities have a weaker relationship to depressed mood in youths than in adults. This may be the case for several reasons. Hammen, Rook, and Harris (cited in Blaney, 1981) found that self-selected pleasant activities were more effective than other-selected pleasant activities in lowering depression in mildly depressed college students. Perhaps positive events are scheduled by others (parents, teachers, and other adults) for children and adolescents more than for adults. For this reason, the pleasant ac- tivities of young people may be less effective than those of adults in combating depression.

Another possible explanation is a statistical one. Because pleasant activities are scheduled by others more for youths than for adults, pleasant activities scores for young people may vary less than those of adults. Decreasing the variance in this way decreases the extent to which a variable can be demonstrated to be correlated with other variables.

Further research should address these issues in examining the differential relation- ship between depressed mood in children and their engagement in pleasant and unplea- sant activities. If the relationship between pleasant activities and depression in children is less than this relationship in adults because of children’s lesser degree of control over their pleasant activities, then this should be demonstrated empirically by scaling plea- sant activities for the degree to which children control them. Similarly, if the relation- ship between pleasant activities and depression is limited in children by attenuation of the range and variance of scores reflecting engagement in pleasant activities, then fur- ther research should identify specific activities that do not have an attenuated range and so may be correlated more closely to mood than other activities.

One limitation of the present study was its use of a normal population. These results may be expected to generalize to clinical populations because 14% of the children ob- tained a CDI score of at least 15, the mean reported by Kazdin, French, Unis, and Esveldt-Dawson (1983) of 20 depressed inpatient children. Further research is necessary to determine whether the results of this study in fact generalize to clinical populations.

Future research also should examine the discriminative powers of the UAS and PAS, or related instruments, in clinical populations. Use of such activity questionnaires may help identify children who, on the basis of their engagement in pleasant and unpleasant activities, may be at risk for depression. In addition, such measures may be useful in targeting behaviors for change in behavioral treatments of childhood depression.

504 Journal of Clinical Psychology, July 1991, Vol. 47, No. 4

REFERENCES

ACHENBACH, T. M. (1978). The child behavior profile: I. Boys aged 6-1 1. Journal of Consulting and Clinical

AL-, E . O . , & GOTLIB, I. H. (1988). The social behavior of depressed children: An observational study. Journal of Abnormal Child Psychology, 16, 29-44.

A ~ R I C A N P s u c m ~ ~ u c ASSOCIATION. (1987). Diagnostic and statistical manual of mental disorders (3rd ed. rev.). Washington: Author.

ASARNOW, J. R., &BATES, S. (1988). Depression in child psychiatric inpatients: Cognitive and attributional patterns. Journal of Abnormal Child Psychology, 16, 601-615.

BLANEY, P. H. (1981). The effectiveness of cognitive and behavior therapies. In L. P. Rehm (Ed.), Behavior therapy for depression: Present status and future directions (pp. 1-32). New York: Academic Press.

BROWN, R. A., & LEWINSOHN, P. M. (1984). A psychoeducational approach to the treatment of depression: Comparison of group, individual, and minimal contact procedures. Journal of Consulting and Clinical

CAREY, M. P., KELLY, M. L., Buss, R. R., & SCOTT, W. 0. N. (1986). Relationship of activity to depression in adolescents: Development of the adolescent activities checklist. Journal of Consulting and Clinical

FAUBER, R., FOREHAND, R., LONG, N., BURKE, M., & FAUST, J. (1987). The relationship of young adolescent Children’s Depression Inventory (CDI) scores to their social and cognitive functioning. Journal of Psychopathology and Behavioral Assessment, 9. 161 -170.

GARBER, J. (1982). The Children’s Events Schedule. Unpublished manuscript, University of Minnesota. GROSSCUP, S. J., & LEWINSOHN, P. M. (1980). Unpleasant and pleasant events and mood. Journalof Clinical

HERSEN, M., BELLACK, A. S., & HIMMELHOCH, J. M. (1980). Treatment of unipolar depression with social skills training. Behavior Modification. 4, 547-556.

JACQ~SON, R. H., L m , B. B., & Smuss, C. C. (1983). Correlates of depressed mood in normal children. Journal of Abnormal Child Psychology. 1 1 , 29-30.

KASLOW, N. J., & REm, L. P. (1983). Childhood depression. In R. J . Morris & T. R. Kratochwill (Eds.), The practice of child therapy: A textbook of methods (pp. 27-51). New York: Pergamon Press.

KASmw, N. J., REm, L. P., & SIEOEL, A. W. (1984). Social-cognitive correlates of depression in children. Journal of Abnormal Child Psychology, 12, 605-620.

-IN, A. E., FRENCH, N. H., Urn, A. S., & ESVELDT-DAWSON, K. (1983). Assessment of childhood depres- sion: Correspondence of child and parent ratings. Journal of the American Academy of Child Psychiatry,

KOVACS, M. (1978). Children’s Depression Inventory (CDI). Unpublished manuscript, University of Pittsburgh. KOVACS, M. (1980). Rating scales to assess depression in school-aged children. Acta Paedopsychiatrica, 46,

LEWINSOHN, P. M. (1974). A behavioral approach to depression. In R. J. Friedman & M. M . Katz (Eds.), The psychology of depression: Contemporary theory and research (pp. 157-178). Washington: Winston-Wiley.

LEWINSOHN, P. M., & AMENSON, C. S. (1978). Some relations between pleasant and unpleasant mood-related events. Journal of Abnormal Psychology, 87, 644-654.

LEWINSOHN, P. M., & G w , M. (1973). Pleasant activities and depression. Journalof Consultingand Clinical

LEWINSOHN, P. M., & Lmm, J. (1972). Pleasant events, activity schedules, and depression. Journal of Ab- normal Psychology, 79, 291-295.

LEWINSOHN, P. M., MERMELSTEM, R. M., ALEXANDER, C., & MACPHILLAMY, D. J. (1985). The Unpleasant Events Schedule: A scale for the measurement of aversive events. Journal of Clinical Psychology. 41,

LEWINSOHN, P. M., & TALKINGTON, J. (1979). Studies on the measurement of unpleasant events and rela-

LDET, J. L., & LEWINSOHN, P. M. (1973). Concept of social skill with special reference to the behavior

WcPHILLAMy, D. J., LEWINSOEN, P. M. (1974). Depression as a function of levels of desired and obtained

MCLEAN, P. D., & Hmsm, A. R. (1979). Clinical depression: Comparative efficacy of outpatient treatments.

PSyChOlOgV, 46, 478-485.

Psychology, 52, 774-783.

PSychology, 54. 320-322.

PSychologV, 36, 252-258.

22, 157-164.

305-3 IS.

PSychology, 41, 261-268.

483-498.

tions with depression. Applied Psychological Measurement, 3, 83-101.

of depressed persons. Journal of Consulting and Clinical Psychology, 40, 309-312.

pleasure. Journal of Abnormal Psychology, 83, 651-657.

Journal of CIinical and Consulting Psychology, 47, 8 18-836.

Children 3 Depression and Activities 505

MULLINS, L. L., SIEGEL, L. J., & H O D ~ K S , K. (1985). Cognitive problem-solving and life events correlates of depressive symptoms in children. Journal of Abnormal Child Psychology, 13. 305-314.

REHM, L. P. (1978). Mood, pleasant events, and unpleasant events: Two pilot studies. Journalof Consulting and Clinical Psychology, 46. 854-859.

SANCHEZ, V . , & LEWSOHN, P. M. (1980). Assertive behavior and depression. Journal of Consulting and Clinical Psychology, 48, 119-120.

STEINMETZ, J. L., LEWINSOHN, P. M., & ANTONUCCIO, D. 0. (1983). Prediction of individual outcome in a group intervention for depression. Journal of Consulting and Clinical Psychology, 51, 331-337.

STRAIJSS, C. C., FOREHAND, R., FRAME, C., & SMITH, K. (1984). Characteristics of children with extreme scores on the Children’s Depression Inventory. Journal of Clinical Child Psychology, 13, 227-231.

SWEARMOTON, E. M., a COHEN, L. H. (1985). Life events and psychological distress: A prospective study of young adolescents. Developmental Psychology, 21, 1045-1054.

TURNER, R. W., WARD, M. F., & TURNER, D. J. (1979). Behavioral treatment for depression: An evalua- tion of therapeutic components. Journal of Clinical Psychology, 35, 166-175.

WIERZBICKI, M. (1984). Social skills deficits and subsequent depressed mood in students. Personalify and Social Psychology Bulletin, 10, 605-610.

WIERZBICKI, M. (1986a). The Pleasant Activities Survey. Unpublished manuscript, Washburn University. WIERZBICKI, M. (1986b). The Unpleasant Activities Survey. Unpublished manuscript, Washburn University. WIERZBICJLI, M. (1987). A parent form of the Children’s Depression Inventory: Reliability and validity in

WmRzBIcxu, M., B M c C m , M. (1988). Social skills, activity level, and subsequent depressed mood in children.

WIERZBICKI, M., 8 SAYLER, M. K. (1989, May). Depression and mood-related activities in normalchildren.

nonclinical populations. Journal of Clinical Psychology, 43. 390-397.

Journal of Clinical Psychology, 17. 203-208.

Paper presented at the meeting of the Midwestern Psychological Association, Chicago.

ASSESSMENT OF SCHIZOPHRENIC INPATIENTS WITH THE MCMI JOHN L. JACKSON, RICHARD L. GREENBLATT, WILLIAM E. DAVIS,

THOMAS J . MURPHY AND KESTUTIS TRIMAKAS

Edward Hines, Jr. Veterans Aflairs Hospital Hines, Illinok

The Millon Clinical Multiaxial Inventory (MCMI) Psychotic Thinking scale previously was found insensitive in the detection of schizophrenia. The MCMI also was shown to be susceptible to undetected “faking good.” We hypothesized that the insensitivity of the MCMI Psychotic Thinking scale was due to an unwillingness of schizophrenic patients to report psychotic symptoms. The MCMI was administered to 258 male schizophrenic inpa- tients who were classified as symptom-reporters or nonreporters based upon whether they endorsed psychotic symptoms on a separate problem checklist. Willingness to report psychotic symptoms was a significant factor in MCMI Psychotic Thinking scale scores as well as many other MCMI scales.

This study was supported by Department of Veterans Affairs basic institutional research funds. Our thanks to Fred Ciba for his clerical assistance. John L. Jackson is now employed by American Biodyne, Inc.,Evergreen Park, IL.

Correspondence that concerns this article should be addressed to Richard L. Greenblatt, Psychology Service (116B), Edward Hines, Jr. Veterans Affairs Hospital, Hines, IL 60141.