Aim: The aim of this study was to define the prevalence of and risk factors for behavioural disorders in children with epilepsy from a rural district of Tanzania by conducting a community-based case-control study. Method: One hundred and twelve children aged 6 to 14 years (55 males, 57 females; median age 12y) with active epilepsy (at least two unprovoked seizures in the last 5y) were identified in a cross-sectional survey and included in this study. Children who were younger than 6 years were excluded in order to eliminate febrile seizures. Behaviour was assessed using the Rutter scale; children who scored 13 or more were considered to have disordered behaviour. A comparison group was made up of age- and sex-matched children without epilepsy (n = 113; 57 males, 56 females; median age 12y). Results: Behavioural disorders were diagnosed in 68 of 103 (66%) children with epilepsy and in 19 of 99 (19%) controls. Disordered behaviour was significantly more common in children with epilepsy than in the comparison group (univariate odds ratio 8.2; 95% confidence interval [CI] 4.3-15.6; p less than 0.001) and frequent seizures and poor scholastic attainment were associated in children with epilepsy. Behavioural disorders were not associated with antiepileptic drug usage. Attention problems were present in 48 of 91 (53%) children with epilepsy and 16 of 97 (17%) controls (univariate odds ratio 5.7; 95% CI 2.9-11.1; p less than 0.001). In children with epilepsy, attention problems were significantly more common in males and were associated with frequent seizures. Interpretation: Children with epilepsy in a rural area of sub-Saharan Africa have a high prevalence of behavioural disorders and attention problems, both of which are associated with frequent seizures. Providing behaviour assessment and appropriate intervention programmes for children with epilepsy may reduce the burden of behaviour disorders in this setting.