Obsessive thoughts with violent, sexual, suicidal or religious content can be highly distressing and impairing for children and teens. Whereas exposure and response prevention (ERP) is the established treatment for pediatric OCD, there is limited literature on the application of ERP for intrusive thoughts in youth. The inherently counterintuitive nature of exposure can increase treatment reluctance in children and teens. Moreover, clinicians may find it challenging to adapt ERP for taboo thoughts, manage their own discomfort navigating ERP, or persuade youth to engage in treatment. Drawing on over 25 years of experience, Dr. Wagner provides a structured and practical ERP approach for intrusive thoughts in youth, highlighting developmental flexibility, collaboration with parents, and respect for family and cultural values. She emphasizes the importance of cultivating treatment readiness and offers four systematic steps to optimize readiness. Using case examples, Dr. Wagner illustrates developmentally-suitable language, metaphors, steps in ERP, and how to engage parents in their child’s treatment.