Childhood epilepsy presents many different challenges requiring a careful assessment and an individual management plan appropriate to the needs of each child. The first rule in managing the difficult-to-treat patient is to re-examine the diagnosis. The characterization of the seizures may also guide the clinician into prescribing the appropriate therapy. If the child has failed to respond to first-line antiepileptic drugs, the situation should be reviewed carefully. There may be a role for one of the new antiepileptic drugs. It is important to treat with adequate doses and for adequate duration before deciding whether a drug is effective or not. Failure to do this may deny the child the benefit of a particular medication. Drugs which affect behaviour or cause lethargy can have a secondary effect on cognition. Failure to treat frequent subtle seizures may also have serious cognitive consequences. Lamotrigine is of value in treating a variety of different seizure types, including subtle seizures, and has a low incidence of adverse effects.