The movie opens at a hospital. Kate Coleman (Vera Farmiga) and her husband, Jon (Peter Sarsgaard) walk in and Kate is clearly pregnant and clearly in labor. While Jon registers at the front desk in the lobby, Kate is wheeled towards the delivery room, but a painful contraction hits and Kate sees she is bleeding heavily. The nurse pushes the wheelchair along as if nothing is happening, but the audience can see blood trailing behind the wheelchair. In the delivery room, Kate is in a lot of pain and asks where Jon is, but nobody will tell her anything. The doctor tells her to relax, but Kate knows something is wrong with her baby. The nurse tells her that the baby is stillborn but they have to deliver it anyway, Kate is in disbelief and tells them that the baby is alive. Before she has time to think, the doctor grabs his scalpel and begins to cut into Kate's stomach, Kate wants to be put to sleep but the doctor says there isn't time. Kate yells and screams as the doctor cuts into her, Jon walks into the room with a video camera and tells Kate that she is doing perfect. After a few seconds, a baby's cry is heard and the nurse hands her a stillborn baby covered in a bloody blanket. Kate screams in terror.Kate springs up in bed after her nightmare. Kate creeps out of bed, without waking Jon, and goes to the bathroom. For a moment, she stares at the large incision scar that goes from her bellybutton all the way to her abdomen. She pops an anti-depressant pill into her mouth and then crawls back into bed with Jon. The next morning, Kate goes to see Doctor Browning (Margo Martindale), her therapist. Kate says that perhaps the nightmares are happening because she and Jon are seeing children that same week, so they can adopt one. She also says that she passed by the liquor store on the way to the office, Doctor Browning asks if she went inside. Kate says she didn't, but she was extremely tempted. Doctor Browning says that she is able to resist that temptation, then she is most certainly able to hold her own as an adoptive mother.Kate goes straight from Doctor Browning's office, to a school for the deaf or hearing impaired. She is greeted by her and Jon's five-year-old daughter Max (Aryana Engineer). Max holds up a picture she drew and Kate says (in sign language, naturally), that it's very beautiful. As Kate is driving home with Max in her car seat, she spots a young man with his child walking together. Kate is so distracted that a large truck almost hits her. Back at home, Kate is playing the piano while something constantly keeps banging against the house. Finally having enough, Kate goes outside and sees Max attempting to shoot a basket. Kate tells her to stop, and Max says that she is sorry, but Kate apologizes and says she shouldn't have yelled. Seconds later, Jon pulls up in the driveway with his and Kate's son, Danny (Jimmy Bennett), who takes the ball from Max and shoots a hoop. Jon takes the ball from Danny and hands it to Max, and lifts her up to the hoop so she can get a basket. Kate tries to say hello to Danny, but he rushes past her to go and play.Later in the night, Kate goes to tuck Max into bed. Max removes her hearing aid, so everything goes silent for a while. Through sign language (and subtitles for us, the audience), Kate asks Max if she wants to read a bedtime story. Max grabs a book, but Kate doesn't seem too happy to read it, but Max begs her. The story is about Max and how happy she was that she was getting a baby sister, but then Baby Jessica died and went to Heaven. Max was happy that she was in Heaven, but wishes that she could've met her. After the story, Max asks if Baby Jessica is an angel. Kate says that is a beautiful angel. After kissing Max goodnight, Kate goes to the bedroom and goes to the bathroom to take her anti-depressant. She is startled when Jon suddenly appears from behind her. Kate and Jon crawl into bed, and Kate says that even though she isn't having second thoughts about adopting, she is excited and nervous. She hasn't felt this way since she thought they were going to bring Baby Jessica home. Jon says that they shouldn't adopt for his sake, Kate says they aren't and that she really wants to take the love she had for Jessica and share it.The next morning, Kate and Jon go to Saint Mariana's Orphanage For Girls. When Kate and Jon get out of the car, they are greeted by Sister Abigail (CCH Pounder) who thanks them for coming. As they walk inside, someone is watching them from a window. When Kate gets the feeling that they're being watched, she looks up to the window but sees nothing. Kate and Jon separate, Kate is shown the girls by Sister Abigail while Jon goes to use the bathroom. Kate and Sister Abigail watch the girls play and Sister Abigail says that adopting an older child isn't an easy decision to make, but Kate says they're ready. Sister Abigail asks where Jon is and Kate says that he is using the bathroom.Jon leaves the bathroom and goes to look for Kate, but stops when he hears the sound of a girl singing. He follows the singing and sees a young girl sitting alone in a room, painting. Jon begins to walk away, when the girl suddenly greets him. Jon steps into the room and the girl introduces herself as Esther (Isabelle Fuhrman), and Jon begins to look through her paintings. They are extraordinary, since Esther seems so young. Jon asks Esther about the painting she is working on, and Esther says that each of her paintings tell a story and that in her current painting, a mother lion is sad because she can't find her cubs. Jon asks why the mother lion is smiling, and Esther says that it's because she is dreaming of her cubs. Jon hopes that she finds them, and Esther says she will and begins to paint in the lion cubs. Kate and Sister Abigail walk in, and Jon introduces Kate to Esther. Esther talks to Jon and Kate, and soon the couple agrees that Esther is the one that they want to adopt. They speak to Sister Abigail in her office, and she mentions that Esther is a rather mature nine-year-old and says that she is very smart and very polite as well. She also mentions that Esther is like a princess, because she wears ribbons around her neck and wrists at all time. Sister Abigail says she will file the paperwork as soon as possible.Jon and Kate take Esther home, and Max rushes out to greet them. Esther uses sign language to greet her, and Max takes an instant liking to her new sister. However, when Danny isn't fond of her. He even asks Jon, rather loudly, why Esther is dressed so differently and Jon quickly shushes him. Esther is thrilled when she sees that they have a piano, and Kate offers to teach her to play and Esther accepts instantly. Jon, Kate, and Max show Esther her bedroom and Esther says that it's perfect and she loves it. Esther is also introduced to Barbara (Rosemary Dunsmore), who is Jon's mother and Esther's new grandmother. A few days later, a celebration is being held in honor of Esther's adoption and this includes presents and cake. Almost like a birthday party. Danny doesn't seem eager to join the family's celebration, and instead plays "Guitar Hero" with his friend, Tyler. As Danny comes close to winning a game, he asks Jon to look but Jon is far too interested in Esther unwrapping his present, which just happens to be a large easel and paint supplies. Esther gives Jon a huge hug and smiles at Danny from over his shoulder. Danny tells Tyler that the game is getting boring, and he leaves. Tyler and Danny's other friend follow him out into the woods near the house. They go to Danny's tree house, and Danny lifts an old board to reveal hidden Playboy type magazines.Kate is in the kitchen, putting away the cake and speaking with Barbara about what she plans to do. Kate says that she'll get Esther settled and then begin to teach again; Barbara reminds her that she said she wouldn't go back to that job. Kate assures her mother-in-law and says that she isn't going back to Yale, but plans to give piano lessons to kids from the house. Barbara doesn't think it's a good idea but Kate says that she just wants some clarity which Barbara knows someone at an AA meeting suggested she needs. Barbara leaves the kitchen and Kate goes back to doing the dishes. Kate looks out of the window and sees Esther pulling Max on a sled over an icy pond. She rushes outside and yells for Esther and Max to get off of the ice and scolds them for playing in such a dangerous area. The next morning, Kate is sending Max and Danny off to school and calls Esther downstairs. Esther comes downstairs wearing a rather old-fashioned dress, which causes Max and Danny to laugh a little bit. Kate sends them to the bus and tells Esther that she should probably change before she goes to school, but Esther says that she likes to wear dresses. Kate gives in and allows Esther to wear the dress to school.The kids arrive at school and the teacher introduces Esther to her class. A girl named Brenda (Jamie Young) teases Esther. Esther says nothing, only stares coldly and walks calmly to her seat. Later that night, Kate runs a bath for Esther. Kate goes to do laundry, but hears Esther lock the door and immediately goes to check if she is all right. Esther unlocks the door and Kate warns that they do not lock doors in the house, but Esther says she was afraid that someone would walk in and see her. Kate assures her that no one will walk in and says she won't even go downstairs until she is done. Esther says she will sing for her because she use to sing to the nuns at the orphanage so that they would know she was all right when she was taking a bath. Kate says okay and goes to finish the laundry. As Kate is putting away Esther's clothes and listening to her sing, she finds that one of Esther's drawers is stuck. After some tugging and pulling, Kate discovers an old bible with a photo of a man inside of it. Kate accidentally drops the Bible and Esther's singing goes quiet, but starts back up after a minute. Kate shoves the Bible back in its hiding spot and continues about the laundry. As she goes down the hall to Max's room, Esther opens the bathroom door and looks coldly out. Obvious, she knew what Kate was up to.In the woods, Danny is shooting paintballs and seems to be enjoying it. Soon, a bird lands on the target and Danny shoots it on purpose. He becomes upset when the bird doesn't move and rushes to see if it's all right. It isn't dead, but it's barely alive and seems to be in pain as the wing is probably broken. Esther and Max suddenly show up and Esther asks what happened, Danny is sobbing and says he didn't think the paintball would hurt the bird. Esther picks up a large brick and asks Danny to put it out of its misery, but Danny refuses. After awhile, Esther takes the brick and beats the bird to death and then throws the brick aside. Danny runs off, horrified by Esther's actions. Esther takes Max's hand and walks away from the dead bird and the blood-covered brick. The next day at school, Esther is passing down the hall at the same time as Danny and Tyler. Tyler comments that Danny's "sister" is a total spaz, but Danny says that she isn't his sister and purposely knocks a book out of Esther's hands. As Esther kneels to pick up the book, Brenda comes along and picks it up for her. When Brenda sees that the book is a Bible, she holds it up and calls Esther a "Jesus-Freak." Esther tries to take the Bible from Brenda, but it soon falls to the floor and the pages scatter everywhere. Esther panics and rushes to pick them up, while a group gathers and begins to laugh at her. Brenda reaches to pull off the ribbon around Esther's neck, but becomes startled when Esther screams and kicks until everyone is silent. Danny is extremely weirded out as Esther continues screaming as though she were possessed.The same day, Kate is giving Esther a piano lesson and Esther castigates herself because she made eleven mistakes. Kate wants to talk about what happened at school, but Esther says that there isn't anything to talk about and leaves. The next day, Jon is with Max and Esther at the park, pushing Max on the swings. Joyce Patterson, the Coleman's next door neighbor, arrives in risqué clothing. Esther listens in on her conservation with Jon, but suddenly becomes distracted when she sees Brenda walking across the playground. After Joyce leaves, Jon becomes a bit nervous and goes to smoke a cigarette while Esther and Max begin to roam the playground. Brenda is nervous as she makes her way towards the slide. She then gets the feeling that she is being followed. As she looks down the slide, Esther comes from behind her and pushes her off. Brenda is in a great deal of pain, as her foot seems to be pulled back. Esther walks away but realizes Max has seen everything so she tells Max that if they want to stay together then she cannot tell anyone what happened. At supper, Jon and Kate are asking Esther about what happened but she says that she and Brenda were playing and she accidentally fell. Kate asks Max if she saw what happened, and Max says that Brenda simply slipped. Max signs something to Danny, but he can't understand her and asks Kate what she said. Esther interrupts and tells him that Max asked for him to pass the bread and butter. Danny says that he wasn't asking her and Esther simply shrugs and begins to cut her steak, and Danny tells her to eat normally and Esther says she is eating normally. Danny asks if that is the way she eats in Transylvania, to which Esther says she is from Russia and Transylvania is in Romania. Danny goes further and says if she was taught that at the school for retards. Jon orders Danny to apologize to his sister, Danny has reached his breaking point and says: "She is not my f*cking sister!" and rushes from the table.As punishment for his outburst, Jon locks up Danny's tree house and says he will unlock it when Danny apologizes to Esther. A few days later, Sister Abigail comes for a visit after being informed of Brenda's accident. As Kate and Jon speak with Sister Abigail about the accident, Esther panics and goes to Max's room and tells her that a "mean lady" is coming to take her away and asks Max for help, and Max agrees. They sneak into Jon's office and begin to search around for the keys to the padlock to the tree house; Max finds some keys and hands them off to Esther. Esther uses the keys to unlock Jon's safe, where she finds a gun, partially loads it and points it directly at Max's forehead and asks Max if she wants to play. Max, clearly frightened, shakes her head and Esther lowers the gun. Max and Esther rush to the bridge that isn't far from the house and they know Sister Abigail's car will pass it. Esther tells Max to stand in front of Sister Abigail's car and wave her hands to get her to stop, but Max is nervous. As Sister Abigail comes driving along, Max is frozen with fear and refuses to move. Having enough, Esther pushes Max onto the road and Sister Abigail slams on the brakes and her car swerves off the road. Sister Abigail climbs out of her car and rushes to a hysterical Max. Sister Abigail asks Max if she is okay, but a shadow looms over her and Sister Abigail looks up, just as Esther beats on her head with a hammer. Sister Abigail is bleeding and unconscious, but Esther knows she will probably wake up soon. She pulls Max to her feet and tells her to stop crying. Esther forces Max to help her move Sister Abigail's body before another car comes along. They push her body down a hill, but Sister Abigail regains conscious and tries to climb back up. Esther grabs the hammer and beats Sister Abigail until she is pretty bloody and definitely dead. Esther takes a traumatized Max up to the tree house and removes her bloody gloves and dress, but Max is still crying. Esther says that if she is caught for the murder, then Max will go to jail with her and tells Max that she won't tell on her if she doesn't tell on Esther. Max agrees and Esther comforts her.As the two are climbing down from the tree house, Danny watches from afar and Esther spots him but walks away anyway. As Danny sleeps, he is startled awake when Esther holds a box cutter blade to his throat and asks him what he saw. He says that he only saw her and Max coming down from the tree house, and Esther says that if he tells anyone than she will castrate him. Danny, clearly upset, accidentally wets himself. She releases Danny and leaves the room calmly. The next day, Kate is dropping Esther and Danny off at their school, and Max at the deaf school. When Esther leaves the car, Kate asks Max and Danny if Esther has done anything to hurt them. Terrified of Esther, they both say no and Danny hops out of the car. As Danny walks up the steps, his bookbag spills but he doesn't notice. Kate leaves Max in the car and goes to hand it back, and is confused because the bookbag was new. As Kate helps Danny, Esther releases the brake and sets the car in neutral. The car rolls down a hill, and Danny quickly warns Kate since Max is still in the car. Kate chases the car and people try to stop it, but it does no good. Finally, the car hits a huge pile of snow, which causes it to stop suddenly. Kate rushes towards the car and quickly pulls Max out, who is thankfully unharmed.That night, Kate and Jon argue about what happened. Kate swears she had set the parking brake, but Jon is still in a bit of disbelief. Jon finally gives in and he and Kate take Esther to Doctor Browning. But things take a bizarre turn when Doctor Browning says that Kate is the one at fault and not Esther. Kate is further frustrated when Jon doesn't even back her up and just remains quiet the entire session, further estranging the couple. The next morning, Jon goes to wake Esther and get her ready for an appointment at the dentist, and Esther startles him by leaping out from underneath the covers. She says that she doesn't want to go to the dentist, and Jon instantly gives into her demand as long as they reschedule and she goes to his office to draw with him (Jon is an architect). In Jon's office, Jon is working while Esther is painting. Esther says that she has waited a long time for a father like Jon, and Jon asks if she waited for a Mother like Kate. Esther pauses and expresses that she feels that Kate doesn't love her, but Jon says that it isn't true that she is just having a hard time getting close to her. He suggests that perhaps she should do something nice for her. Esther agrees. As Kate is in the kitchen, Esther comes and says that she has a surprise for her. She holds out a bundle of white roses that Kate recognizes instantly. They were the roses from Baby Jessica's dedication garden. Kate snaps and grabs Esther by the arm, and Esther lets out a scream. Jon hears the commotion and Esther runs off sobbing, while Jon comforts Kate who is weeping openly as she crumples on the floor and looks down at the roses. While Kate is in the greenhouse, still upset about the orchid, Esther sneaks into the tool shed and grabs a screwdriver. She wraps it in a rag and places it in her mouth, and then places her arm inside of a vice. She tightens the vice until her arm breaks and then goes to bed and cries for Jon that her arm still hurts from where Kate grabbed her. Horrified by the bruises on Esther's arm, Jon takes her to the doctor.Kate goes up to her bedroom and sees Esther laying in her and Jon's bed, and being comforted by Jon. Jon tells Kate that she broke her arm, but Kate argues that she didn't really grab Esther that hard. Jon says that it would be best for Kate to sleep downstairs. Kate contemplates drinking but decides not to after seeing the pond that almost cost Max her life. She pours the wine down the sink and sleeps downstairs. A few days later, Doctor Browning is called to the house and Kate still defends herself and says that she didn't hurt Esther at all. At that moment, Jon places two wine bottles out on the table. He tells Kate that Esther found them, which simply infuriates Kate but Jon can't help but ask if Kate is beginning to drink again. Doctor Browning is wondering the same thing as well. Kate defends herself again and says that she thought about drinking the wine but poured it down the sink, along with one of the bottles. Jon asks why she has the other bottle then, and he and Kate argue. Finally, Jon drops the bombshell: If Kate doesn't go into rehab, and then he will divorce her and take the kids with him. At the top of the stairs, Max listens in and Esther comes really close to her and whispers that she will shoot Kate if she tells. The next day, Danny sneaks to Max's room and asks her if she knows anything about Esther and Max confesses by showing Danny the pictures of Brenda's accident, Sister Abigail's death, and the car accident. Max also tells him that the hammer and Esther's bloody clothes are up in the tree house, Danny tells Max that once they get the hammer that Jon and Kate will believe them and Esther will be locked away. Unfortunately, Esther overhears the entire thing.The next day, Danny sneaks up to his tree house and searches for the hammer and clothes but can't find them. Esther suddenly appears and throws the hammer and the clothes to the floor. She tells him that Max will be arrested to for helping her, but Danny says that Max was forced to do it. Esther pours lighter fluid over the evidence and lights a match, setting the evidence and the tree house on fire. She escapes and locks the tree house up with Danny still inside it, and simply watches with a smile as Danny screams for Kate. Danny crawls out a window, but it's too late and the tree house crumbles and Danny is rendered unconscious and completely broken, but miraculously alive. As Esther lifts a rock to finish him off, Max pops out of nowhere and pushes Esther before she can do anything, and Kate arrives just in time. At the hospital, the family waits for word on Danny's condition. A doctor comes and says that Danny is alive and in stable condition, Kate asks if he will remember anything and the doctor says they'll have to wait awhile before they know. Kate and Jon walk away for a while and Kate says that either Esther or Danny started the fire, and Jon says that he doesn't know which one did it. Kate is frustrated by Jon but gives in and says she'll go to rehab only if Esther leaves the house at the same time. Esther asks Barbara for a dollar for the soda machine and then walks out of the waiting room, with no intention of getting a simple drink. She sneaks into Danny's room, removes the heart monitor from his finger (and puts it on her own so no one will know there is a problem) and tries to suffocate him with a pillow. Max, getting the feeling that Esther is up to something, goes to get Kate. Meanwhile, Esther, thinking she has killed Danny, puts the monitor back on his finger and alarms go off. The doctors rush down the hall to Danny's room. He has flatlined. Kate and Jon panic, but breathe a sigh of relief when Danny has a pulse and is stabilized again. Kate freaks out and knows Esther did something, She screams at Esther, calls her a bitch, and then slaps her hard. Orderlies sedate Kate while Jon comforts Esther and watches sadly as his wife drifts to sleep. When Kate wakes up, she is groggy but sees Jon is with her, she asks if Danny is okay and Jon says that they are running some tests and he should be home in a few days. He also says that he is taking Esther and Max back to the house, Kate makes him promise that Esther will get nowhere near Max. Jon says nothing and leaves the room to take the girls home.As Jon is tucking Max in, Esther comes into the room and Max becomes frightened. Esther wishes her sweet dreams and kisses her forehead, stealing her hearing aid. Jon finishes putting Max to bed and Esther walks away, Max soon falls asleep and Jon leaves the room. Jon, clearly upset by all that has happened, finds the wine and pours quite a few glasses. Suddenly, Esther comes downstairs wearing tons of makeup and a revealing dress, but Jon is so drunk that instead of getting angry, he sobs openly and tells Esther that he is scared for Danny. Esther assures him that he is a wonderful husband and father, and also tells him that she loves him. When Esther comes onto him, Jon comes back to reality and yells at her to go to her room. Esther runs to her room, sobbing hysterically as the makeup streams down her face. Meanwhile, Kate is resting in the hospital when she gets a call on her cell phone. It is Doctor Varava from the Saarne Institute in Estonia, he says he received the picture of Esther and asks where she is. (The Saarne Institute isn't an orphanage. It's a mental institution.) Kate says that she is at the house with her husband. Doctor Varava warns Kate to call the police and get her family out of the house; Kate says that Jon won't believe her. He then tells Kate to tell Jon that Esther is not nine-years-old. She is a grown woman, named Leena Klammer, and is actually 33 years old; she as one of their most violent patients, who disappeared some time ago. Kate is in disbelief and Doctor Varava says that the scars on her neck and wrists from her straitjacket. Kate realizes why Esther wears the ribbons around her neck and wrists: to cover the scars . The scene cuts to Esther, who now looks horrible. She has wiped off all her makeup, removes her fake teeth, and the ribbons from her neck and wrists. She now looks more like a hag than an innocent child. Jon goes on the search for Esther in her room but finds she isn't there, but he does discover something. In the black light of the aquarium he sees Esther's paintings for what they really are: images of violence and sex. Jon is mortified but continues on the search, just as the lights go out. He goes downstairs to the electric panel and is stabbed by Esther, but is still alive. Esther stabs him repeatedly, then looks at the top of the stairs and sees that Max has witnessed the whole thing.Max runs off and hides, Esther grabs Jon's gun from the safe and goes on the search for Max. Thankfully, Kate has escaped from the hospital and races to the house. The road is so slick though, that when Kate arrives she crashes through the house and alerts Esther who is upstairs searching for Max. Kate discovers Jon and breaks down, but her concern lies with Max. Esther finds Kate and shoots her in the shoulder, but Kate is okay and continues the search for Max. We see that Max is in the greenhouse and hiding behind the plants, she is relieved when she sees Kate on the roof of the greenhouse but Kate tells her to be quiet because Esther is there. Just as Esther is about to discover Max, Kate screams and Esther shoots at her. The roof is made of glass, so the bullet shatters it and Kate comes crashing down on top of Esther. Max waits anxiously before Kate regains conscious and grabs Max and runs. Kate takes Max down to the pond and comforts her, just as she sees police cars pull up to the house to arrest Esther. When the police enter the house, they search the entire household but when they come to the greenhouse, Esther is gone. At the pond, Kate is continuing to comfort Max when Esther suddenly lunges at her with a knife. Kate and Esther wrestle each other down a hill and right onto the pond, with Max watching on in terror. The gun flies out of Esther's hand as she and Kate wrestle, landing only a few yards away from Max. Esther slashes Kate's other shoulder with the knife, but Kate kicks her off before she can stab her. Max grabs the gun and holds it up, being only four and not knowing how to fire; Max aims and shoots the ice instead of Esther. The ice cracks and breaks, and both Esther and Kate fall into the freezing waters. They both fight under water before Kate kicks Esther and resurfaces. As Kate is climbing out of the water, Esther pops up and grabs onto Kate's legs, the knife hidden behind her back. Esther says, Please don't let me die, Mommy." Kate finally loses it and yells "I'm not your f*cking Mommy!" and kicks Esther hard, breaking her neck. Esther sinks back down and Kate escapes with Max.
Output: Question: who are experiencing strains in their marriage after their third child is stillborn?, Answer: Max