Children with problematic asthma represent about 0.5% of the population but consume a disproportionate amount of healthcare staff time and resources. The most important step in managing children with problematic asthma is differentiating those with genuine severe, therapy resistant disease from those who have difficult to treat asthma for a variety of other remediable factors. The most common causes of poor symptom control are poor adherence to therapy, ongoing exposure to sensitized allergens or co-morbid psychosocial problems. In up to half of the children with problematic asthma, addressing these simple factors can avoid further escalation of treatment or more invasive investigation. All asthmatic children with poor control despite treatment with ≥ 800μg of inhaled budesonide (or equivalent) should be referred to a paediatric respiratory specialist for evaluation. Management of children with problematic asthma, and particularly those with genuine severe therapy resistant disease, requires a stepwise multidisciplinary approach.